tag:blogger.com,1999:blog-14885595501029038232018-03-29T07:00:25.287-07:00Challenging Dogma - Fall 2014Michael Siegelhttp://www.blogger.com/profile/09937031813339167454noreply@blogger.comBlogger16125tag:blogger.com,1999:blog-1488559550102903823.post-42870019583451805652015-01-23T12:05:00.000-08:002015-01-23T12:05:39.149-08:00#WeAreAllWorthy: A Critique and Response to StopBullying- Paola Peynetti <div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Introduction<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .25in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">Bullying is a major problem in schools and workplaces all over the world. It is a “multifaceted form of mistreatment, characterized by the repeated exposure of one person to physical and/or emotional aggression including teasing, name calling, mockery, threats, </span><span style="background: white; font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">harassment, taunting, hazing, social exclusion or rumors” (17). The World Health Organization has documented a wide range of bullying prevalence worldwide. </span><span style="font-family: &quot;Georgia&quot;,serif;">As all public health and societal problems, bullying is the consequence of a complex network of socially constructed image and personality stereotypes and ‘labels’ promoted and fueled by mass media, interconnected discriminatory behaviors and actions against people from with different race/ethnicity, gender, sexual orientation, body image, and even hobbies and interests. In the realm of public health, bullying is an enormous problem—it is the emotional and/or physical abuse that has detrimental effects not only in the physical and mental health of the victim—even mortality, but also on their academic/professional performance, self-esteem, continuous systematic and interpersonal discrimination of ethnic/sexual minorities, and future of the victim as possible victimizer.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .25in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The U.S. government’s StopBullying.gov campaign is failing to protect victims and prevent further victimization of individuals in schools, as most of its proposals are innately misled from individual health behavior models, such as the Health Behavior Model, the Transtheoretical Model, and the Theory of Planned Behavior—as analyzed below, the approach towards bullied students fuels victim-blaming and helplessness, the response towards bullies fails to address the roots of the abuse, and the advice for parents and teachers is not strong enough to change their behavior in a progressive, understanding, way, maybe only their attitudes—then they become an authoritative figure nobody wants to listen to. Today’s Western value system emphasizes the ability of the individual to control his or her own personal fate. However, this focus on the connection of social conditions to single diseases via single mechanisms at single points in time neglects the multifaceted and dynamic processes through which social factors may affect health and, consequently, may result in an incomplete understanding and an underestimation of the influence of social factors on health (11). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .25in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">Social epidemiologists and psychologists have continuously concluded “multidisciplinary efforts are needed at a community level to provide effective interventions” (13). There is also an urgent need to reframe the issue (22) in the social construct of how bullies, victims, and bystanders react. StopBullying.gov fails to acknowledge and respond to the intersectionality of other oppressive systems that facilitate bullying, such as racism, discrimination, sexism, homophobia, stigma, domestic violence, mass media reach and patriarchy. We urgently need a “reconceptualization of lifestyle” (7) in collective action instead of individual, self-interested competition. The intervention #WeAreAllWorthy is a multidimensional movement using social networks, allyship, the urge for safe spaces, good citizenship, and the prevention, protection, and respect of basic human rights for <u>all </u>to defeat bullying.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Critique Argument 1: Victim Blaming Is Counterproductive and Fuels Stigma<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span lang="ES-US" style="font-family: &quot;Georgia&quot;,serif; mso-ansi-language: ES-US; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">The Federal Government’s campaign’s advice to victims is, “If speaking up seems too hard or not safe, walk away and stay away. Don’t fight back. Find an adult” (19). This advice is innately flawed because of three reasons, all connected to individual health models with wrong assumptions or to a wrong approach to social health models.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span lang="ES-US" style="font-family: &quot;Georgia&quot;,serif; mso-ansi-language: ES-US; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">First, asking children to walk away and not fight back automatically gives more power and control to the bully. Control is a crucial core value that people want in their lives, and by giving it to the bully, the victim feels even more dependent on and further victimized by the system.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span lang="ES-US" style="font-family: &quot;Georgia&quot;,serif; mso-ansi-language: ES-US; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Second, this continued “victim-blaming” of the campaign, through further Labeling, saying not to provoke or go near the bully, not to fight back or speak back at them, only strengthens the victim’s hopelessness: if he/she’s the victim and the system is telling him/her that it’s impossible to fight back and one must only stay away, it’s turning the blame on the victim for being in the same space as the bully. It’s like blaming a rape victim for what she’s wearing or what party she was in instead of blaming the rapist or the bully for the abuse.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span lang="ES-US" style="font-family: &quot;Georgia&quot;,serif; mso-ansi-language: ES-US; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Third, the campaign tells students to report to the school, but often this reporting is not anonymous and the victim sufferes further abuse—this point thus assumes that the victim is in a vacuum and that the environment is receptive to reports. Social Cognitive Theory (15) is the least restrictive of the individual models, but it still assumes a dynamic, ongoing process in which personal factors, environmental factors, and human behavior exert influence upon each other” (14). The intervention is asking too much of the victims- if the environment is abusive, violent, and full of stigma, its influence on the individual’s thoughts and actions will be negative and victims will not feel comfortable or safe reporting to a school that continues to fail them. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Critique Argument 2: Punishing the Bullies Fails to Address the Roots of Abuse<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The campaign follows a traditional approach towards the bullies, or abusers, punishing them in the same way that other students are punished for completely different reasons. Bullying is thus treated in school rules as just one more behavior that is forbidden, yes, but not adequately handled. Bullying is a much more complicated problem than smoking, or eating in class, or speaking during a test—this abuse permanently scars the emotional and physical health of another human being. Following are three reasons why this privation of freedom is counterproductive and also fails to address the roots of the abuse.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">First, bullies are punished through not being able to go outside during recess, or an extra study period, etc. and also sometimes through forced instructions on how to stop bullying other students. This is based on the Transtheoretical Model (9), which concludes that a model where change takes place in stages is best (Pre-contemplation</span><span style="font-family: Wingdings; mso-ascii-font-family: Georgia; mso-char-type: symbol; mso-hansi-font-family: Georgia; mso-symbol-font-family: Wingdings;">à</span><span style="font-family: &quot;Georgia&quot;,serif;"> contemplation</span><span style="font-family: Wingdings; mso-ascii-font-family: Georgia; mso-char-type: symbol; mso-hansi-font-family: Georgia; mso-symbol-font-family: Wingdings;">à</span><span style="font-family: &quot;Georgia&quot;,serif;"> preparation</span><span style="font-family: Wingdings; mso-ascii-font-family: Georgia; mso-char-type: symbol; mso-hansi-font-family: Georgia; mso-symbol-font-family: Wingdings;">à</span><span style="font-family: &quot;Georgia&quot;,serif;"> action</span><span style="font-family: Wingdings; mso-ascii-font-family: Georgia; mso-char-type: symbol; mso-hansi-font-family: Georgia; mso-symbol-font-family: Wingdings;">à</span><span style="font-family: &quot;Georgia&quot;,serif;"> maintenance). Unfortunately, it not only fails to find incentives for good behavior and maintenance of that good behavior, but it also doesn’t even consider the roots of the abuse. Bullies aren’t going to sit during lunch break on Monday contemplating how their abuse might be hurting their victim, and by Thursday they’re <i>Most Compassionate Student.</i> Any trigger, such as being abused themselves, can absolutely take them to an unpredictable jump, backwards or forwards in this model.<i> </i>Furthermore, the alternative model of Psychological Reactance (18) states that whenever an individual feels that its freedom is being threatened, it will do whatever it takes to restore that anxiety and get that freedom back. This means that anytime a student is punished at school for bullying or breaking any other rule, they’ll react to that threat or that punishment by exerting their power and control over other students even more than before. The bully wants to maintain his/her position of power and autonomy to call others names or beat others up, so maybe <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">Second—and maybe the most important failure of this campaign, is that it doesn’t directly address the psychological causes of bullying. Teachers recognize that the abuse may be a consequence for past or parallel victimization of the abuser, but in the context of school rules and action steps, the bully is not a victim, but a rule-breaker. Studies have continuously shown that the victim-bully cycle is fueled by the Social Learning Theory (the most comprehensive of the individual theories). Studies of violence and abuse have discussed the role of social learning theory in the victim-offender cycle of abuse, finding that “victims of abuse are often more likely to be disruptive, aggressive, and violent than their non-abused counterparts” (12, 15). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">Third, the campaign explicitly tells kids to “be nice” (which again touches on Psychological Reactance), but it fails to consider the social norms of schools and of mass media telling kids that abuse and name-calling increases the social status of the bully within their individual social networks. The campaign is advocating for the Theory of Planned Behavior (9), where individuals should go through a rational, cognitive decision-making process. However, this model fails to consider subjective norms associated with that behavior. Even if the bully considered decreasing or stopping the aggression, peer pressure of more bullies or of the popular or ‘cool’ kids in the school would encourage him to act irrationally and continue the violence.&nbsp; Some bullies are bullied to bully, and individual models fail to recognize the social network where students face this stigma, abuse, and norms. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Critique Argument 3: How Adults Are Promoting the Wrong Values<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">StopBullying.gov also has an unrealistic and incomprehensive approach towards teachers and parents in the community. The campaign fails to understand the unrealistic optimism of parents who don’t believe in bullying and teachers who choose to ignore the problem; it also stresses the adults’ attention on victim-blaming again; lastly, it fails to recognize the social norms of reinforced prejudice and stigma that kids mimic from adults around them. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; First, it is worth mentioning again the Health Behavior Model’s (9) assumption that it’s the victim’s fault that he or she is being bullied. The model states that each individual considers his/her perceived susceptibility, severity, benefits of action, and barriers of action—meaning the costs and benefits of particular actions, which should result in rational decision-making.&nbsp; This theory then rationalizes that a situation of youth violence is a consequence of a victim not measuring the costs and benefits of their behavior correctly and ending up in the wrong place at the wrong time. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Second, this campaign fails to acknowledge the predictable irrationality (1) of the parents and teachers who are supposed to be role models and examples for their students and children. As the adults in the community, these individuals are responsible for not only advocating for kindness, respect, and equality, but also for <i>showing </i>these behaviors and actions by example. The campaign fails to address the normalized and institutionalized racism, sexism, prejudice, homophobia, and abuse within families, communities, and workspaces also. If students are being told not to bully but they’re being shown violence, discrimination, and injustice, they’re going to mimic the behaviors and silence the advice. (15)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Third, the campaign is unaware of the Theory of Optimistic Bias and of the Law of Small Numbers, therefore, parents and teachers choose to ignore signs of abuse rationalizing it as unlikely to happen to <i>their </i>students or <i>their </i>children. These theories have shown how that people tend to think they’re invulnerable, but they expect others to be victims of misfortune, not themselves. Studies have repeatedly confirmed that “cognitive and motivational considerations lead to predictions that degree of desirability, perceived probability, personal experience, perceived controllability, and stereotype salience would influence the amount of optimistic bias evoked by different events” (21). Therefore, just as police departments and administrators of universities deny sexual assault prevalence in their schools because it <i>must be sure happening somewhere else, but not here, </i>teachers and parents rationalize that because they didn’t suffer bullying or because they’ve never seen it—because they know only a few kids who aren’t bullied they assume nobody is, especially their kids (Law of Small Numbers), they don’t assume the problem with all of its complex causes and connections to other forms of violence, aggression, and bad parenting or teaching.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Intervention idea: #WeAreAllWorthy<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The StopBullying.gov campaign is failing to recognize the importance of social health behavior models. It isn’t acknowledging the negative impacts of victim blaming, the strong propaganda-like effects of violent, disrespectful, competitive behavior of celebrities and TV stars in their shows and movies and in real life. The campaign also fails to recognize the victim-bully cycle and the psychological causes of youth abuse. It doesn’t create safe spaces where victims, allies, and victimizers can safely learn about stigma, about community values, or about taking control of their own safety and actions through a collective effort of everyone remotely involved. Most importantly, the campaign fails to identify the real cause behind bullying, discrimination, and physical and mental health consequences of the abuse: the real cause is the socially constructed culture and space of competition, individuality, injustice, racism, patriarchy, sexism, homophobia, and corporate control of people’s (including children) identity and desires. The World Health Organization states “enacted legislation </span><span style="background: white; font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">has placed the responsibility of prevention on the shoulders of organizational (educational or workplace) management with no apparent input expected from the public health sector” (17). </span><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;This must stop as we re-think the role of public health professionals and public health frameworks for public policy and social norms. The intervention #WeAreAllWorthy is a multidimensional campaign and movement the crucial function of understanding social networks, allyship, the urge for safe spaces, good citizenship, and the prevention, protection, and respect of basic human rights for <u>all </u>(freedom of expression, freedom of speech, freedom from persecution and violence, etc.) in the fight against bullying. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Intervention Defense 1: #TakingControl </span></b><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">First and most essential, the campaign must be understanding and appealing. For victims and allies, the intervention should not just be a policy or a new rule or a new punishment for against their bullies and only in the classroom. The intervention should be a movement that gives the victims of bullying the control and autonomy that they lost from the abuse. It’s important to note that in order for this movement to be appealing, it must be as inclusive as possible. Using the Diffusion of Innovation Theory (16), it will start with victims and their friends/siblings, but as soon as enough people consume the product (or join the movement), then everybody will join as well. This movement will be called&nbsp; #WeAreAllWorthy,&nbsp; #TakingControl. It would be not only a social media campaign and also a very comprehensive, well-developed curriculum in schools. The program would be branded (using Advertisement and Marketing Theories) with a positive message, nothing about victims but about survivors, not about bystanders but about allies, not about individuals but about a team. The curriculum would have an extra class with discussions on different mental health and community development topics, collective reflection, safe space discussions, and conversations on diversity, acceptance, respect, body image, stereotypes, etc. It would also have an anonymous confidential section where students could speak to a peer ally and also a counselor about their experience with youth violence or abuse. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">Another key point of this intervention is that the leaders of this movement will be older peers who stand as allies to the younger student survivors. Malcom Gladwell’s <i>The Tipping Point</i> (10)<i> </i>explains that “all epidemics have tipping points,” as soon as a specific number of students join the movement and become part of the campaign, everybody else will also join. Studies have shown that in schools with severe bullying problems, students believe and are committed to peer support systems, and teachers have a mostly positive view of the intervention (3). Furthermore, Maslow’s Hierarchy of Needs explains that unless students have their basic needs met—including safety, community, belonging, love, etc., then asking them for personal development and understanding of others is not realistic or reasonable. This is why the campaign would have to address basic needs: after water, housing, food, there’s family, community, security—these are the most important requirements for children to develop as community members and leaders: belonging and love. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Intervention Defense 2: #AllyForSafeSpace<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The most critical point to address when including the bullies and victimizers into the campaign above is to acknowledge the high probability that they have of having been victims themselves, and of understanding the social norms and also social community, environmental, psychological causes of their actions and behavior. The victimizers would also be part of this campaign and group counseling sessions—and it is essential that these conversations foster core values of love, security, equality, role models, safety, and belonging. Older kids will be trained and serve as the leaders of these groups along with mental health professionals and teachers—however, these older “cool” or more popular kids will be the ones passing the message on, with the theme and title #AllyForSafeSpace, as Social Expectations Theory (2) has shown that people are social beings, they depend on and follow those who they deem more fit, more popular, more able, more attractive, more intelligent, etc. If this campaign has as leaders, trained and educated older kids who will serve as mentors for younger peers and talks to them about the above-mentioned topics, then it is more likely to be attractive to young victimizers instead of a campaign where the teacher reprimands all students who participate in aggression.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">There’s another important point to mention: discrimination and aggression against sexual minority though is significantly higher than among heterosexual populations. Homophobic bullying is pervasive among children and adolescents in schools- as well as in workplaces:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 115%; margin-left: .5in; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;“Students who frequently experience homophobic bullying are at an elevated risk of several negative outcomes, including depression anxiety, hostility, mental health symptoms, health problems poor school functioning school absenteeism, substance use risky sexual behaviors post-traumatic stress disorder self-harm and suicidal behavior…. Researchers and practitioners have recognized the importance of a framework that considers assessment of risk and protective factors beyond the individual-level, as emerging evidence suggests that certain environmental factors have a profound effect on homophobic bullying in school… There’s been some initiatives for interventions in an ecological system of individual, micro, exo, and macro actions and campaigns.”&nbsp; (17, 20)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Intervention Defense 3: #PassItOn<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The last point of this intervention would be a mass media campaign with celebrities and personal stories aimed not only at changing kids behavior but also parents and teachers’ behavior and attitudes with regards to their everyday lives. These adults are examples/role models for their kids, and because of the intersectionality of this problem—with racism, homophobia, discrimination, individualism, etc. Parents and teachers thus will therefore learn from celebrities about bullying, good citizenship, the extra class, and the vulnerability of their kids to any form of mental and physical aggression by other kids (because of Optimism Bias, they didn’t think their kids would be bullied…). The message for teachers will also talk about the damage of bullying and of allowing for a normalized level of youth violence in schools, because studies have proven that “Teachers with stronger beliefs that bullying is normative were less likely to intervene to stop bullying, and lack of intervention was in turn related to higher levels of peer victimization in their school” (8).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The most important part of this campaign is that the message is not shooting statistics and blaming adults of bad-parenting, but it’s going to show them, with subliminal but well-structured messages, how to act in front of their kids to be more consciencious about their words, behavior, and actions with regards to race, gender, respect, violence, and conflict resolution. This campaign will appeal to strong core values of family, equality, and safety, and it’ll be successful due to Agenda Setting Theory (22) and also to Advertisement and Marketing theories (mentioned above). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Conclusion </span></b><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">It’s important to change the framing of this issue of bullying and stop blaming the victim, punishing the victimizers with no rehabilitation or dialogue, and start including parents, older kids, friends, and teachers alike in the movement to end stigma, end discrimination, and end youth violence. “<span style="border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in;">The scientific literature suggests that preventative interventions should include whole community awareness campaigns about the nature of bullying and its dangers. Efforts should also be made to enhance the emotional and organizational environments in school and work settings by promoting sensitivity, mutual respect and tolerance to diversity while prohibiting bullying” (17). It is also important to remember that referral to appropriate health services will be required to alleviate the physical and emotional consequences of bullying. This campaign is branded; it’s a movement that people want to join, belong to, and share stories in. Through social&nbsp; and behavioral science theories that aim to change the community’s behavior, through marketing and branding, and through understanding the multisectorial aspect of the problem, the #WeAreAllWorthy campaign will end all the failures of the StopBullying.gov initiative. Let’s #JoinTheMovement!</span><o:p></o:p></span></div><div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;"><b>References</b><o:p></o:p></div><div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoListParagraph" style="margin-left: .25in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">1)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Ariely, Dan. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: HarperCollins, 2008. Print.<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoListParagraphCxSpFirst" style="margin-left: .25in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">2)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span class="apple-converted-space"><span style="background: white; font-family: Georgia, serif;">&nbsp;</span></span><span style="background: white; font-family: Georgia, serif;">Cohen, Reuven. "Marketing Influence: The Power of Persuasion."<i>Forbes</i>. Forbes Magazine, 22 May 2012. Web. 13 Dec. 2012.</span><a href="http://www.forbes.com/sites/reuvencohen/2012/05/22/marketing-influence-the-power-of-persuasion/"><span style="background: white; color: #666666; font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">http://www.forbes.com/sites/reuvencohen/2012/05/22/marketing-influence-the-power-of-persuasion/</span></a><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p></o:p></span></div><div class="MsoListParagraphCxSpLast" style="margin-left: .25in; mso-add-space: auto;"><br /></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">3)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Cowie, Helen and Olafsson, Ragnar. The Role of Peer Support in Helping the Victim of Bullying in a School with High Levels of Aggression. <i>School Psychology International </i>2000, 21: 79-95. </span><a href="http://spi.sagepub.com/content/21/1/79.full.pdf+html"><span style="font-family: &quot;Georgia&quot;,serif;">http://spi.sagepub.com/content/21/1/79.full.pdf+html</span></a><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">4)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">De Fleur ML, Ball-Rokeach SJ. <i>Theories of Mass Communication </i>(5<sup>th</sup> edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">5)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Following the herd (Chapter 3). In: Thaler RH, Sunstein CR. <i>Nudge: Improving Decisions About Health, Wealth and Happiness. </i>New Haven, CT. Yale University Press, 2008, pp. 53-71.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">6)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Fox, James Alan. <i>Why Anti-Bullying Programs Fail. </i>Crime and Punishment. Boston Dot Com. </span><a href="http://www.boston.com/community/blogs/crime_punishment/2010/08/why_anti-bullying_programs_fai.html"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.boston.com/community/blogs/crime_punishment/2010/08/why_anti-bullying_programs_fai.html</span></a><span style="font-family: &quot;Georgia&quot;,serif;">. Web. Accessed Dec. 9<sup>th</sup>, 2014.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">7)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Freudenberg N, Galea S. The impact of corporate practices on health: implications for health policy. <i>Journal of Public Health Policy </i>2008; 29:86-104. <o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">8)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Hektner, Joel and Swenson, Christopher. Links from Teacher Beliefs to Peer Victimization and Bystander Intervention: Tests of Mediating Processes. <i>Journal of Early Adolescence </i>32 (4), 516-536.<i> </i></span><a href="http://jea.sagepub.com/content/32/4/516.full.pdf"><span style="font-family: &quot;Georgia&quot;,serif;">http://jea.sagepub.com/content/32/4/516.full.pdf</span></a><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">9)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Individual health behavior theories (chapter 4). In: Edberg M. <i>Essentials of Health Behavior: social and Behavioral Theory in Public Health. </i>Sudbury, MA: Jones and Bartlett Publishers<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">10)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Introduction. In: Gladwell M. <i>The Tipping Point: How Little Things Can Make a Big Difference. </i>Boston: Little, Brown and Company, 2000, pp. 3-14. <o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">11)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Link BG, Phelan J. Social conditions as fundamental causes of disease. <i>Journal of Health and Social Behavior </i>1995; 35 (extra issue): 80-94. <o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: .25in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">12)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"></span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Ma, Xin. Bullying and Being Bullied: To What Extent Are Bullies Also Victims?. <i>American Educational Research Journal</i>, Vol. 38, No. 2 (Summer, 2001), pp. 351-370. Published by: American Educational Research Association. Article Stable URL: </span><a href="http://www.jstor.org/stable/3202462"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.jstor.org/stable/3202462</span></a><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoListParagraph" style="margin-left: .25in; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">13)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"></span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Marks DF. Health psychology in context. <i>Journal of Health Psychology </i>1996; 1:7-21.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">14)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">National Cancer Institute. <i>Theory at a Glance: A Guide for Health Promotion Practice. </i>Part 2. Bestheda, MD: National Cancer Institute, 2005, pp.9-21 (NIH Publication No. 05-3896). Available at: </span><a href="http://www.cancer.gov/PDF/481fd53-64df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.cancer.gov/PDF/481fd53-64df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf</span></a><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l1 level1 lfo1; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">15)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. <i>Health Psychology: </i>2003; 22:424-428.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><span style="font-family: &quot;Georgia&quot;,serif;">15) Olweus, D. (1993). Bullying at school: what we know and what we can do. Oxford:<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><span style="font-family: &quot;Georgia&quot;,serif;">Blackwell.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: .25in; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">16)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"></span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Rogers, Everett M. Diffusion of Innovations. New York, Free Press of Glencoe. 1962. Print.<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoListParagraph" style="margin-left: .25in; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">17)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Srabstein, Jorge and Leventhal, Bennett. <i>Prevention of bullying-related morbidity and mortality: a call for public health policies.&nbsp; </i>World Health Organization Bulletin. 2010. </span><a href="http://www.who.int/bulletin/volumes/88/6/10-077123/en/"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.who.int/bulletin/volumes/88/6/10-077123/en/</span></a><span style="font-family: &quot;Georgia&quot;,serif;"> Web. Accessed Dec 9<sup>th</sup>, 2014.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: .25in; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">18)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"></span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Silvia PJ. Deflecting Reactance: The role of similarity in increasing compliance and reducing resistance. <i>Basic and Applied Social Psychology </i>2005; 27:277-284.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">19)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">StopBullying.gov. What Can You Do (Kids). </span><a href="http://www.stopbullying.gov/kids/what-you-can-do/index.html"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.stopbullying.gov/kids/what-you-can-do/index.html</span></a><span style="font-family: &quot;Georgia&quot;,serif;">.&nbsp; Web. Accessed Dec. 9<sup>th</sup>, 2014<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">20)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Sung Hung, Jun, and Garbarino, James. Risk and Protective Factors for Homophobic Bullying in Schools: An Application of the Social-Ecological Framework. <i>Educ Psychol Review </i>(2012) 24: 271-285. Web. </span><a href="http://download.springer.com.ezproxy.bu.edu/static/pdf/201/art%253A10.1007%252Fs10648-012-9194-y.pdf?auth66=1418285242_b2c3ff0a460085d0e167da435c05c46b&amp;ext=.pdf"><span style="font-family: &quot;Georgia&quot;,serif;">http://download.springer.com.ezproxy.bu.edu/static/pdf/201/art%253A10.1007%252Fs10648-012-9194-y.pdf?auth66=1418285242_b2c3ff0a460085d0e167da435c05c46b&amp;ext=.pdf</span></a><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">21)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Weinstein ND. Unrealistic optimism about future life events. <i>Journal of Personality and Social Psychology </i>1980, 39: 806-820.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 21.3pt; text-indent: -21.3pt;"><br /></div><div class="MsoListParagraph" style="margin-left: 21.3pt; mso-add-space: auto; mso-list: l0 level1 lfo2; text-indent: -21.3pt;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">22)<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif;">Winett L. Advocates guide to developing frame memos (Chapter 46). In: Ivengar S, Reeves R, eds. <i>Do the Media Govern? Politicians, Voters and Reporters in America. </i>Thousand Oaks, CA: SAGE Publications, Inc., 1997, pp.420-432.<o:p></o:p></span></div><br /><div class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph;"><br /></div>Emily Maplehttp://www.blogger.com/profile/10711700934258818531noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-83208819601119112522015-01-23T12:02:00.002-08:002015-01-23T12:02:41.364-08:00The California Dream of Justice & Terror of Mental Illness: A Behavioral Indictment Of The “Three Strikes and You’re Out” Policy – Ryan Manganelli<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif;">Justice is not served best with a singular solution. For the United States, the path to justice is undeniably intertwined with incarceration. Compared to all other nations of the world, with a staggering 2.2 million inmates, the United States possesses the largest imprisoned population in the world (</span><a href="http://www.sentencingproject.org/template/page.cfm?id=107"><span style="font-family: &quot;Georgia&quot;,serif;">1</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). America’s most populated state (</span><a href="http://www.ca.gov/About/Facts.html"><span style="font-family: &quot;Georgia&quot;,serif;">2</span></a><span style="font-family: &quot;Georgia&quot;,serif;">), the Golden State, California played a major role in augmenting the nation’s incarcerated population over the last twenty years. Enacted in 1994, California’s Proposition 184, or as the infamous piece of legislation is also titled, the “Three Strikes and You’re Out” policy was crafted with the intent of deferring repeat criminal offenses. As the title denotes, under the “Three Strikes” policy, Californian criminals are punished relative to the amount of felony offenses they have committed. Repeat offenders receive twice the sentencing length otherwise mandated by law for their second offense and a third offense leads to a life imprisonment with the minimum term being 25 years </span><a href="http://www.lao.ca.gov/2005/3_strikes/3_strikes_102005.htm"><span style="font-family: &quot;Georgia&quot;,serif;">(3</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). The law catalyzed a tremendous influx of jailed prisoners in California since its enactment. Beyond the ethical and legal dilemmas posed by the Proposition 184, the law offers profound implications for the public health sector of California. In particular, the incarceration of criminals suffering from severe mental illness creates a need for systematic reform. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif;">Examining the “Three Strikes” policy through the lens of behavioral science provides a medium to address the disenfranchisement of mentally ill prisoners in the state of California. One of the nation’s most prestigious academic institutions, Stanford Law School has launched the discussion regarding Proposition 184’s role in the imprisonment of the mentally ill with their publication “When Did Prisons Become Acceptable Mental Health Care Facilities?” According to Stanford’s extensive report, approximately 45 percent of Californian inmates are suffering from a mental illness. The most alarming disparity highlighted in the report is the disproportionate number of inmates sentenced to life in prison under the “Three Strikes” law. Prisoners sentenced under the “Three Strikes” law are nearly twice as likely to be mentally ill compared to other California prisoners (</span><a href="https://www.law.stanford.edu/sites/default/files/child-page/632655/doc/slspublic/Report_v12.pdf"><span style="font-family: &quot;Georgia&quot;,serif;">4</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). Rather than establishing public institutions that assist the mentally ill prisoners combat their diseases, the state of California is shackled by its inadequate criminal justice legislation, the “Three Strikes” policy. Stemming from such inadequate policies, a vicious cycle plagues people who are mentally ill not only in California, but also the entire nation. In the fractured mental health care system of the United States, people diagnosed with severe mental illnesses face tremendous barriers to receive the necessary medical care to manage their illness. When severely ill patients are left untreated, the unfortunate reality of their illness manifests in the form of erratic and illegal behavior (</span><a href="http://www.pbs.org/wgbh/pages/frontline/released/stories/"><span style="font-family: &quot;Georgia&quot;,serif;">5</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). With a policy such as the “Three Strikes” rule, mentally ill criminals are relegated to serving as cogs in the vicious cycle of repeated imprisonment and neglected treatment. Indicting Proposition 184 with several evidence-based social and behavioral science theories can bring the Golden State closer to justice. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;<b>Issues of Stigma </b><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Consider the trajectory of a prototypical civil rights movement. Each civil rights trajectory can be placed in the confines of a narrative with heroes and villains. With each civil rights narrative, the villain is continually embodied by an ominous social phenomenon – stigma. Ervin Goffman, one of the most influential sociologists of the 20<sup>th</sup>century, was a founding scholar in the examination of stigma as a social concept. &nbsp;By Goffman’s foundational account, stigma is a reference to a social attribute (race, occupation, religion, sexual orientation, educational status etc.) that is labeled as “deeply discrediting” by the “normals,” or exclusive factions in a society (6). Stigma plagues the socially discredited in a cyclical fashion. As Patrick Corrigan outlines, stigma unfolds in a three-part act: signals, stereotypes, and discrimination. Physical characteristics and language exuded by the stigmatized provide signals for exclusive members of society to construct stereotypes about discredited factions. With the stereotypes on the conscious of the elite, the discredited faction is subject to confront discrimination in various arenas of social life (7). As investigative journalism published in the New York Times reveals, the “Three Strikes” policy has created a medium for California to stigmatize the mentally ill. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif;">Dale Curtis’ confrontation with the “Three Strikes” policy exemplifies the villainous nature of stigma. Curtis is a 55 year-old, Californian male who suffers from mental retardation and schizophrenia. Multiple non-violent, robberies of negligible monetary values committed by Curtis earned him three strikes in the California court of law. The tragedy of stigma ultimately confronted Dale Curtis in the courtroom. Although Curtis displayed severe episodes of mental impairment during questioning and with the negligence of his public defense attorney to mention his extensive record of illness, Curtis was awarded the status quo, life sentence for his third strike (</span><a href="http://www.nytimes.com/2012/11/25/opinion/sunday/california-horror-stories-and-the-3-strikes-law.html?_r=0"><span style="font-family: &quot;Georgia&quot;,serif;">8</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). Corrigan’s three-part act of stigma was exemplified in the case of Dale Curtis. Through his actions in the courtroom, Curtis provided the surrounding audience signals to justify stereotypes and discriminatory sentencing. Despite the clearly visible signs and records available to validate Curtis’ illness, the court opted to discredit his illness and ignore mental health care treatment options. Addressing issues of stigma can alter the tragic course of mental illness in California to form a story of triumph &amp; redemption.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">The Role of Social Norms</span></b><span style="font-family: &quot;Georgia&quot;,serif;"> <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Before detrimental stigmas around mental illness can be resolved, there is a pressing social issue underlying the phenomena of stigmatization. Perceived social norms of mental illness are at the foundation of the injustice perpetuated by the “Three Strikes” policy. &nbsp;Social norms are beliefs shared within a social environment (school, occupational setting, church, city, etc.) regarding a set of behaviors or “customary codes.” The theory of planned behavior explains the potential for social norms to impact communities. Before an individual can reach an intention to facilitate a certain behavior, the attitude that individual holds toward the particular behavior is influenced by the prevalent social norms in an environment (9). The perceptions individuals share of one another and the nature of social interactions are tremendously impacted by the prevalent social norms shared in an environment. Social norms have the potential to influence the manner that human beings treat one another. Stigmatizing and discrediting social norms regarding mental illness can further complicate disparities of mental health among individuals in a social setting. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif;">One recent study featuring a cohort of undergraduate students demonstrates the role perceived social norms have in the stigmatization of mental illness. In the study’s primary experiment, the students were asked to describe their level of comfort to interact with individuals who display symptoms of schizophrenia and depression, as designated by the Diagnostic and Statistical Manual of Mental Disorders. Before the investigators assessed the subjects’ comfort in the hypothetical scenarios, they assessed the subjects’ perceived social norms of behaviors and personal beliefs related to mental illness using questionnaire instruments. Ultimately, the analysis revealed an association between subjects reporting less comfort with interaction among mentally ill people and perceived normative expectations about general behavior (10). The study validates the role of social norms in the stigmatization of mental illness. If people approach those battling a mental illness with discrediting preconceived notions, the ill are subject to face discrimination and stigma. Dale Curtis’ story mirrors the conclusion of the social norms study. Curtis’ symptoms and history of illness were subsequently discredited and approached with tremendous social distance, or an ambivalent interaction based on a set of collectively recognized norms in a social group (11). Perhaps, discrediting institutional norms regarding mental illness were at the foundation of Dale Curtis’ stigmatized experience.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Frames that Make the Mentally Ill Invisible <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Perspectives surrounding the implementation of the “Three Strikes” policy and subsequently proposed amendments completely ignore the role played by California’s criminal justice system in the manifestation of mental illness. With the aid of framing theory, California’s ignorance toward the mental health of its inmates can be brought to the forefront.&nbsp; Framing is the manner in which information is packaged and arranged to convey an intended connotation, or message is framing (12). Polarizing issues, such as policies surrounding incarceration and the treatment of mental illness, evoke a vast spectrum of frames in the media and political forums. In the construction of public policies, framing creates a significant impact on the perspective of voters and politicians in their consideration of issues debated in legislative arenas. One of the fundamental tasks in frame analysis is identifying the core values, or the “appeal to principle” offered by a frame presented in the media. Core values are terms that link the underlying position of the frame and its attempt to resonate with an ideal that is ubiquitously valued in society (13). With the use of core values, frames have the power to influence which values and beliefs are instilled within a society. In the case of the “Three Strikes” policy, the frames surrounding the policy neglect to include health as a core value.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif;">Proposition 36 is the most recent proposal on behalf of California’s legislature to mend the oversight embedded within the “Three Strikes” policy. Established in 2012, Proposition 36 raised the valid concerns of revising the “Three Strikes” policy to save the state money and continue to ensure the safety of its citizens. One glaring piece was missing in the frames constructed to support Proposition 36 – an emphasis on the mentally ill prisoners who are marginalized by the “Three Strikes” policy. Safety, justice, and economics are core values disseminated throughout Proposition 36’s website Fix Three Strikes. The highlighted potential benefits of the proposition include: “saves California over $70-100 million annually,” “restores the original intent of the Three Strikes law,” and “no rapists, murders, or child molesters will benefit from Prop. 36”(</span><a href="http://www.fixthreestrikes.com/about"><span style="font-family: &quot;Georgia&quot;,serif;">14</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). While public safety, resurrecting California’s budget, and incarcerating legitimate felons are valid concerns built upon core values that resonate with the public, there are no statues in Proposition 36 that speak to the mental health burden of inmates. As the Stanford report examines, the lack of attention devoted to the mentally ill that are incarcerated under “Three Strikes” sentencing has consequences. While nearly 1800 prisoners reaped the benefit of gaining a revised sentence following the Proposition 36 approval, 75 percent of the inmates denied a revised sentence after the proposition was passed were mentally ill (4). Proposition 36 was an opportunity to leverage the influence of framing theory to afford the mentally ill who are imprisoned by the “Three Strikes” a path to seeking treatment. The unfortunate reality is that frames in support of Proposition 36 neglected health as a core value and the negligence continues to haunt prisoners struggling with illness. Frames provide an outlet to bring an issue, not unlike prisoners battling mental illness, from subterranean media and advocacy circles to the center of mass media. With the use of health and equality focused frames, citizens imprisoned by mental illness will be granted a previously absent voice and platform in the conscious of the public.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Campaign to Address Social Norms &amp; Stigmatization<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Mental health is gaining momentum in reaching the center of public health interventions and awareness campaigns. On the other hand, outreach and campaign efforts specific to mental illness within the criminal justice system are incredibly scarce. Invisible social issues, like the oppression of the mentally ill through imprisonment, require drastic social measures to foster legitimate social change. In the plight of the mentally ill who are imprisoned, establishing a campaign to raise awareness of Proposition 184’s role as an oppressor is the necessary social measure. Marketing principles can lend the necessary tactics to construct an effective campaign aimed at debunking stigma and reframing social norms of mental illness among the incarcerated. Social marketing, in particular, is a theoretical model pertinent to what would best assist the design of a mental illness social norm campaign. The ultimate goal of social marketing is to garner effective campaigns by utilizing principles of commercial marketing (product planning, pricing, communication, and marketing research) to leverage influence on the acceptability of social ideas and norms. To achieve significant social change, the principles of commercial marketing must address historical, cultural, political, and social environments surrounding an issue (15). Each component, or tool offered by social marketing can be applied to the predicament of the mentally ill affected by the “Three Strikes” law to design an effective social norms campaign. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif;">Historically, California has struggled with transitioning from the deinstitutionalization of mental illness in the 1960’ s-1970 and subsequent&nbsp; “emptying” of the ill released from closed state hospitals to prisons during the proceeding decades (4).&nbsp; While California legislature has offered several policies to address mental health, such as the Mental Health Services Act in 2004, politically the state has been silent on issues of mental illness among the incarcerated. Considering the stigma encountered by Dale Curtis in the courtroom, the social environment in California surrounding mentally ill criminals is not one of reconciliation. With the historical, political, environmental, and social factors surrounding the “Three Strikes” law in mind, social marketing tools can be leveraged to design an effective campaign aimed at changing the social norms regarding mentally ill prisoners. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif;">Building a social norms campaign with a product, price, place, promotion, and partnership as the pillars of intervention is paramount in the design phase. In particular, considering the product disseminated in social media, television, and print campaign materials will foster the most relevant campaign to a 21<sup>st</sup> century audience. The product, or an immediate benefit (15) to be acquired by the audience (the state of California) in the case of the norms campaign is an abstract commodity – social purpose. For instance, in promotional material, the issue of incarcerating the mentally ill can be framed as the current generation’s marquee civil rights issue. To illustrate the campaign’s product, compiling images of mentally ill persons in hospital gowns behind prison bars with images of the 1960’s civil rights movement, or the AIDS movement of the 1980’s will add historical relevance to the campaign. Like previous generations, the current generation can acquire social purpose by participating in a social movement. Politically, the campaign can engage the audience by instituting a pledge for Californians to call on their representatives and senators to craft legislative action that aids the mentally ill whom the “Three Strikes” law repeatedly oppresses.&nbsp; If the historical and political components are successful, the goal of systematic social change will follow. With social marketing, a social issue can be afforded a social resolution and newfound visibility. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Establish Multi-Dimensional Care Options <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></b><span style="font-family: &quot;Georgia&quot;,serif;">Mental illness is an immensely complex issue that requires multi-faceted solutions. Combine the difficulty of managing a mental illness with confronting the criminal justice system on a regular basis, and the issue becomes even more baffling. Maslow’s “Hierarchy of Needs” is a behavioral model that resonates with the complex and multi-dimensional nature of mental illness. Utilizing Maslow’s hierarchical model as a platform to design treatment programs for mentally ill and legally troubled populous, such as those affected by the “Three Strikes” policy, provides an outlet to compartmentalize a densely faceted issue. Abraham Maslow devised his theory to identify the most fundamental human needs, which when fulfilled, can lead to the achievement of “self actualization.” The diverse array of human needs highlighted by Maslow includes: physiological, safety, love and belongingness, esteem, and self-actualization. If all of the fundamental needs are met, individuals theoretically reach an empowered state of being that spawns the development of critical thinking and problem-solving abilities (16). Addressing the “Hierarchy of Needs” for the mentally ill poses a valid model to provide coordinated care to mental health patients and assist those who frequently confront the law assimilate into society, rather than prison. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; On a national scope, there are examples of health care facilities that provide treatment options to assist mentally ill patients meet their “hierarchy of needs.” Bridgeview Manor is an adult care home in Ashtabula, Ohio that provides mental health treatment to patients suffering from severe mental illnesses who have also served prison sentences. The facility was featured in PBS’ <i>Frontline </i>documentary series, “The Released,” which depicts the plight of mentally ill prisoners in the United States. In <i>Frontline’s</i> interview with the Bridgeview Manor director, Sherri Sullivan, she acknowledges the mentally ill patient’s unique need for assistance with routine tasks (physiological needs), such as practicing daily hygiene and preparing meals. Regaining connection with family members (love and belongingness), access Social Security and Medicaid Benefits (safety), and motivational interventions (esteem) are other services that Bridgeview Manor offers to patients.&nbsp; Sullivan also noted about the patients at Bridgeview, “they need a lot of additional help that's not available particularly in an outpatient community setting” (</span><a href="http://www.pbs.org/wgbh/pages/frontline/released/bridgeview/sullivan.html"><span style="font-family: &quot;Georgia&quot;,serif;">5</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). Although operating a facility like Bridgeview Manor poses significant funding and administrative challenges, the facility offers an outstanding example of how mental health patients leaving prison should be treated. If California allocated more resources in community settings to address the unique “hierarchy of needs” for the mentally ill, versus imprisoning the ill as a substitute for treatment, self-actualization for the mentally ill can be realized.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Enhance Public Defense &amp; Police Mental Health Training<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Modifying the norms of an institution is approachable through the use of individualized behavioral models. To prevent future instances of stigma within legal forums, such as the case of Dale Curtis, bolstering mental health training programs for criminal justice authorities in California is a viable solution. For the design of such training programs, social cognitive theory provides a behavioral framework to assist legal authorities transcend prejudice thought regarding mental illness and embrace social differences in their line of work. Social cognitive theory (SCT) is a dynamic behavioral model that focuses on the relationship between individual factors, environmental variables, and subsequent human behavior. At the core of SCT, is the classic nature-versus-nurture debate – are individuals a product of their environment, or is the environment a product of the individuals? According to SCT, the adoption of new behavior causes both the onset of social modifications that alter the individual and the environment (17). In the plight of the mentally ill affected by the “Three Strikes” law, the previously suggested interventions are aimed at creating environmental, or macro-level social changes. California’s individual, or micro-level solution: adopt SCT-modeled training programs for figures in the state’s criminal justice system. Through the use of a SCT model, law enforcement, judicial, and correctional professionals can develop the self-mastery to constructively interact with mentally ill persons, to recognize symptoms of illness, and to identify safe and ethical methods to coerce untreated individuals experiencing heightened states of illness. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Patrick Corrigan also presents thought provoking literature regarding the dynamic between social-cognition, institutional stigma, and life-chances for the oppressed. Corrigan expresses the dynamic in a formulaic manner. As a product of social cognitive function, authoritative individuals exercise institutional stigma, which pressures society to undermine access to care (18). Because of pressures in the courtroom (environment) and the negligence of the judicial and legal professionals (individuals), Dale Curtis did not receive equal due process (discrimination and stigma). Expanding mental health training programs for California’s criminal justice system will reconcile the environmental and individual elements in Dale Curtis’ narrative. The National Alliance for Mental Illness (NAMI) offers one of the most comprehensive law enforcement mental health training programs in the country – Crisis Intervention Training (CIT). With a bi-dimensional program design, CIT combines an individual component: “training for law enforcement to improve response to people experiencing a mental health crisis;” and an environmental component: “a forum for partner organizations to coordinate diversion from jails to mental health services” (</span><a href="http://www.nami.org/Template.cfm?Section=CIT&amp;Template=/ContentManagement/ContentDisplay.cfm&amp;ContentID=150503"><span style="font-family: &quot;Georgia&quot;,serif;">19</span></a><span style="font-family: &quot;Georgia&quot;,serif;">). CIT focuses on social cognition by intervening the approach of individual police officers and the approach of communities, or larger social environments to treating mental illness. By addressing the individual and environmental components of the SCT model, the CIT program is a shining example of an alternative approach to incarceration of the mentally ill. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Conclusion<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></b><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;Managing mental illness is an immense challenge for both individuals and societies. The complexity of addressing the issue is beyond daunting. In the world of criminal justice, the complexities of mental health serve as an excuse to perpetuate the oppression of the mentally ill through imprisonment. Embracing social differences will allow societies to mitigate the consequences of inadequate and antiquated policies, such as the “Three Strikes” policy. Campaigns to address social norms, establishing more multi-dimensional community mental health care facilities, and funding criminal justice mental health training programs, are viable interventions to address the systematic disenfranchisement of the mentally ill in California. Social endeavors are a balance of exercising patience and urgency. Profound societal change does not transpire instantaneously, yet the consequences of injustice do not rest. <b><o:p></o:p></b></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">REFERENCES</span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: 0px;"></div><ol><li><span style="font-family: Georgia, serif; line-height: 200%; text-indent: -0.25in;">The Sentencing Project. <i>Incarceration.</i>The Sentencing Project. </span><a href="http://www.sentencingproject.org/template/page.cfm?id=107" style="line-height: 200%; text-indent: -0.25in;">http://www.sentencingproject.org/template/page.cfm?id=107</a><span style="line-height: 200%; text-indent: -0.25in;">.</span></li><li><span style="font-family: Georgia, serif; line-height: 200%; text-indent: -0.25in;">State of California. <i>Facts. </i>Sacramento, CA: State of California. </span><a href="http://www.ca.gov/About/Facts.html" style="line-height: 200%; text-indent: -0.25in;"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.ca.gov/About/Facts.html</span></a><span style="font-family: Georgia, serif; line-height: 200%; text-indent: -0.25in;">.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;</span></span><span style="font-family: Georgia, serif; text-indent: -0.25in;">Legislative Analyst’s Office. <i>A Primer: Three Strikes – The Impact After More than a Decade. </i>Sacramento, CA: Legislative Analyst’s Office. </span><a href="http://www.lao.ca.gov/2005/3_strikes/3_strikes_102005.htm" style="text-indent: -0.25in;"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.lao.ca.gov/2005/3_strikes/3_strikes_102005.htm</span></a><span style="font-family: Georgia, serif; text-indent: -0.25in;">.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Stanford University. <i>When Did Prisons Become Acceptable Mental Healthcare Facilities?</i> Stanford, CA: Stanford Law School – The Three Strikes Project. 2014.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;</span></span><span style="font-family: Georgia, serif; text-indent: -0.25in;">Public Broadcasting Services. <i>Frontline – The Released.</i> Arlington, VA: Public Broadcasting Services. </span><a href="http://www.pbs.org/wgbh/pages/frontline/released/" style="text-indent: -0.25in;"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.pbs.org/wgbh/pages/frontline/released/</span></a><span style="font-family: Georgia, serif; text-indent: -0.25in;">.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Goffman E. Stigma: Notes on the management of spoiled identity. Englewood Cliffs, N.J: Prentice-Hall. 1963</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Corrigan P. Mental health stigma as social attribution: Implications for research methods and attitude change. <i>Clinical Psychology: Science and Practice</i> 2000; 7: 48-67.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">8.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp; </span></span><span style="font-family: Georgia, serif; text-indent: -0.25in;">Staples B. <i>California Horror Stories and the Three Strikes Law. </i>New York, New York: New York Times, 2012.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Edberg M. Individual health behavior theories (pp. 35-49). In: Edberg M. Essentials of Health Behavior: Social &amp; Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;</span></span><span style="font-family: Georgia, serif; text-indent: -0.25in;">Norman, R. et al. The role of perceived norms in the stigmatization of mental illness. <i>Social psychiatry and psychiatric epidemiology</i> 2008; 43: 851-859.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Karakayali, N. Social Distance and Affective Orientations1. <i>In Sociological Forum </i>2009; 24: 538-562.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Menashe, C. &nbsp;Siegel, M. The power of a frame: an analysis of newspaper coverage of tobacco issues-United States, 1985-1996. <i>Journal of health communication</i> 1998; 3: 307-325.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Winett, L. Advocate’s Guide to Developing Framing Memos (Chapter 46). IN: Iyengar S, Reeves R, eds. <i>Do the Media Govern? Politicians, Voters and Reporters in America. </i>Thousand Oaks, CA: SAGE Publications, Inc., 1997, pp.420-432.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Three Strikes Reform. <i>About Proposition 36. </i>NAACP Legal Defense and Educational Fund, Inc. </span><a href="http://www.fixthreestrikes.com/about" style="text-indent: -0.25in;"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.fixthreestrikes.com/about</span></a><span style="font-family: Georgia, serif; text-indent: -0.25in;">.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Siegel, M, &amp; Doner, L. Marketing principles applied to public health (pp.203-228). In: Siegel, M, &amp; Doner, L. <i>Marketing public health</i> Gaithersburg, Maryland: Aspen Publishers, 1998.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Simons, J, et. al. Psychology - The Search for Understanding. New York, NY: Drinnien West Publishing Company, 1987.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">National Cancer Institute. <i>Theory at a Glance: A Guide for Health Promotion Practice. </i>Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896).</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">Corrigan, P. How Stigma Interferes With Mental Health Care. <i>American Psychologist </i>2004; 614-625.</span></li><li><span style="font-family: Georgia, serif; text-indent: -0.25in;">National Alliance for Mental Illness. <i>Crisis Intervention Training – FAQ.</i> Crisis Intervention Training. Arlington, VA: National Alliance for Mental Illness. </span><a href="http://www.nami.org/Template.cfm?Section=CIT&amp;Template=/ContentManagement/ContentDisplay.cfm&amp;ContentID=150503" style="text-indent: -0.25in;"><span style="font-family: &quot;Georgia&quot;,serif;">http://www.nami.org/Template.cfm?Section=CIT&amp;Template=/ContentManagement/ContentDisplay.cfm&amp;ContentID=150503</span></a><span style="font-family: Georgia, serif; text-indent: -0.25in;">.</span></li></ol><br /> Emily Maplehttp://www.blogger.com/profile/10711700934258818531noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-60459578035696496092015-01-23T11:58:00.001-08:002015-01-23T11:58:52.695-08:00Enriching The Lifestyles Of Children With Down Syndrome With The Use Of Behavioral Theories - Hurain Khan<div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Introduction<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Children with special needs receive various responses from families and communities all over the nation. There have been many attempts to reduce the discrimination and improve these children’s quality of life. Trisomy 21, or Down syndrome, in particular has experienced discrimination fueled by ignorance that needs to be reversed. A general approach that is taken to improve these children’s lives is the use of individualized therapy sessions, separated classroom settings, and distinctive learning goals (1). There is only so much that these interventions can accomplish in the physical, mental, and social growth of a child with Down syndrome. Here, we will examine flaws with these types of programs and how to improve the details to reach a more favorable outcome in developmental abilities and learning outcomes. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Current Approach<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; There are numerous programs throughout the U.S and the world that are dedicated to the wellbeing and health of children with Down syndrome (1)(2). It is very important to ensure their overall health is assessed and that they are not at risk for heart and growth complications. Clinical and classroom settings that set these individuals apart from those without developmental delays are not beneficial after a certain age. Separated facilities should not be the lifelong focus for individuals and families with Down syndrome. As they grow older and remain healthy, they develop social and interpersonal needs as well. These are clearly represented in Maslow’s Hierarchy of Needs and it is completely logical that this would also apply to individuals with Down syndrome (3). Many approaches that are in place today focus only on the physiological and safety levels, which are helpful, but severely restrictive in lifestyle. The focus now, especially for adolescence, should be the belonging, the self-esteem, and the self-actualization levels. This really is just as important, if not more important to children with Down syndrome in order to feel like they are capable of the same things that anyone else is. Here are a few ways that many current approaches do not support these long-term needs. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Argument 1<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; When a parent discovers that their child has Down syndrome, whether it be prenatally or at the time of birth, they often feel like this is their personal problem and that they have to do something about it right away. Fortunately, the option of termination is becoming much less popular, but it does still exist (4). Parents and families make assumptions about what their child’s lifestyle and even their own lifestyles will be like throughout the child’s life. There are aspects of Leon Festinger’s theory of Cognitive Dissonance playing a role here. This theory states that an event that brings about a feeling of discomfort causes someone to want to take action in order to bring back a sense of comfort and balance (5). Parents may feel that the presence of Down syndrome is something that has disturbed their idea of consistency and that they need to adjust it to make it go back to normal. It is perfectly reasonable for a parent to want to take action to improve their child’s life, but sometimes over-action or over-care can be just as detrimental to the child’s future. However, parents and families often receive skewed messages of how to handle and work with a child with Down syndrome and that it should be particular and distinctive from a child without a developmental delay. This pre-conceived notion that special care is needed is often exaggerated and does not give enough credit to the child. When children are given too much extra attention and special care that other children their age do not receive, it creates something of a barrier between them and their peers. This is not the goal; we want children with Down syndrome to feel as if they are not treated differently and that they can accomplish what anyone else can. This presence of support and motivation is helpful, but it must come with appropriate motives. There are definitely benefits that come from these programs, but they are only part of what should be going on. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Argument 2<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Another flaw with these approaches is the pressure that is put on parents to fix things. Health care professionals and other organizations are using some seemingly inspirational techniques from the Theory of Planned Behavior. These ideas include enforcing certain attitudes upon people about a behavior to change and what the perceived norms are of doing that behavior. These are combined with intention and self-efficacy, and it assumes that behavior change will automatically be made (6). The idea of treating the growth of a child as the behavior to change is not appropriate. Parents often feel like they can fix this problem and lessen the negative effects that it has, or even use the technique to aspire to be in the norm. A few flaws with this theory are that it is encouraging parents to make a change in their child’s life with the wrong purpose, and it is not very useful for long-term behaviors or actions. This is precisely the case with children with Down syndrome. For a parent to want to “fix” their child based on perceived norms about what their child should be like is having a skewed intention of what is best for them. The intention behind the use of this theory is admirable, but the information being put across is not what we want parents to hear and relate to. This would involve parents being adamant about sending their eight-year-old child to a specialized classroom that is separate from everyone else and that only includes other students with developmental delays. The intention is present and there is self-efficacy for doing the right thing, but the deprivation of being around other children is definitely disadvantageous. The individualization of this approach is what constricts the mental and developmental growth of these children. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Argument 3<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Finally, those who implement these programs and health plans for parents with Down syndrome realize that taking action and continuing to take action throughout their child’s life is a way of being in control over something that happened against their will. Down syndrome is not a desired outcome, so this allows for them to be able to take some action and feel good about it. The programs and systematic interventions intended for children with special needs to undergo are restrictive of long-term goals and benefits. Being able to make a difference in how one’s child is raised and treated may give the illusion of control. This is a proposed theory by Ellen Langer that explains how people tend to prefer feeling like they have control over a situation even when that may not be the case (7). However, by doing so and trying to control and mediate the experiences a child growing up with Down syndrome has, it really ends up taking away from the more positive practices and skills that they could learn on their own with less interference. As with the majority of parents, having control over teenagers is desirable but quite difficult. Adolescents with Down syndrome should be able to experience freedom to explore and be able to learn from these same environments. Not only will this improve their social skills and self-esteem, but they will thrive in the situations they are put in because they will be able to work and solve problems more efficiently, thus boosting their self-esteem. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Overview<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; All in all, individualized programs have good intentions and they are appropriate to ensure the health of a child with Down syndrome early on. However, there comes a point when these programs are restrictive and do not help children advance as far as they could if they were in more typical settings. By using influential explanations of behavior change, the skills that these children learn are constrained rather than allowed to flourish. Shifting these kinds of program to using more social models will allow more growth among adolescents with Down syndrome and their peers. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">New Intervention<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; As a typical child grows older, he or she ideally develops friendships and experiences that serve as pivotal social situations to growth and learning. Preventing a child from experiencing these necessary components of childhood is a great disservice to their social skills, particularly in a child with Down syndrome. Christopher Kliewer helps explain that there are so many factors that can change the way they experience the world and the opportunities that they are given (8). One way to do this would be to ensure that children with Down syndrome and other special needs are able to socialize and relate with other children that can help advance their development. Our new intervention will be based primarily in classrooms of elementary schools, middle schools, and even high schools. In order for them to flourish socially and psychologically, inclusion is key. Students with Down syndrome will have some individualized attention to assist with their academic success, such as reading, writing, and mathematics, but they will spend a large portion of their day with the same schedules and classroom time as everyone else. This integration will not only help them learn better and adapt to their environment, but their classmates will be able to collaborate and work with them in order to provide a stronger, more close-knit environment. In addition, it is really important for adolescents with Down syndrome to not feel cast aside or alienated from their classmates. Setting all the children on a more socially balanced level will allow them to feel as if they have equal opportunities to succeed and participate. This intervention of inclusion and integration will help these individuals to feel assisted based on their needs, but with the freedom to explore and expand their limits and goals.<o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Defense 1<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The first flaw in current approaches was about the message being given to parents to do the right thing and take steps to fix the problem that they have been presented with. The parents care very much, but we need to redirect this energy in the proper direction for something more positive. Individuals with Down syndrome are capable of many things, so long as they are given the chance. Our intervention will have an effective way of showing parents a different perspective on what their child’s life can be like and how Down syndrome does not have to obstruct their dreams. This message will be particularly effective when it comes from someone who means it and understands what a parent’s role is. It should also be someone that parents can connect with and look up to for comforting guidelines and encouragement. For this, we would use Down syndrome advocates Eva Longoria, with her own organization, Eva’s Heroes, Jamie Foxx, who is a stakeholder at the Global Down Syndrome Foundation, and Lauren Potter, the <i>Glee </i>actress with Down syndrome (9). Longoria and Foxx both have sisters with Down syndrome and they have had personal experiences with being told to take the assumption that their respective sisters would not live fulfilling lives, but they were given countless opportunities anyway and they have accomplished great things and lead happy lives (10)(11). This is the message we want to portray to encourage parents who may not know what Down syndrome entails and how to best “fix” it. Potter can go further to explain what her lifestyle is like and the opportunities she received throughout childhood that help her thrive. With these messages, we are employing Robert Craig’s Communication Theory, which simply shows that if an audience feels connected with the communicator, they will be much more likely to take the information to heart and understand it better (12). Seeing these celebrity advocates will have a familiarity factor and parents will be better persuaded to enrich the opportunities for their own child.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Defense 2<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The next step we want to take is to fix the issue that stands regarding making a change to improve their child’s life. Instead of using an individual-centered intervention based on the Theory of Planned Behavior, we need to look at society and the environment and adjust how they function in those situations. We will use the Social Expectations Theory founded by Joseph Berger, which helps our goal by showing that a behavior is best formed by being done in large groups that can be imitated (13). By spreading our campaign advertisements, billboards, and posters all over the nation, we will be able to inform many people and transform the idea of inclusion of all people with special needs. Down syndrome will be better known and there will likely be much less discrimination. Changing the norm is really going to speak to parents and families and help them feel more comfortable with the idea of raising a child with Down syndrome. It will also improve the ways that current approaches attempt to solve the problem of having to take action right away. This campaign will help change people’s mindsets, which will change their behavior, which will spread very quickly. This process will take a snowball effect and it will be so rewarding for parents to feel secure about the ambitious lifestyles their children can have and that they do not have to be limited in any way. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Defense 3<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Finally, we want to completely reverse the meaning of control. Parents should definitely be able to experience control, but so should their children. As they grow older, they are already aware that they are different from other people, so this should not be reinforced by the system. The environment needs to be welcoming and accepting of everything they want to do. The control that was dubbed an illusion will now become more concrete with the implementation of our campaign and there will be confidence in what they can accomplish. The idea of this control will duplicate that of the progress Down syndrome has made in the nation in the last 50 years. Michelle Sie Whitten, the Executive Director of the Global Down Syndrome Foundation, illuminates this timeline and how things have changed. Prior to the 1980’s, individuals with special needs in general were often institutionalized just for being different and this brought about the assumption that they were not capable of living like “normal” humans. It was assumed that it was impossible for them to carry out regular activities like eating, dressing, communicating, and living past 28 years of age. After these practices were considered inhumane and the focus shifted, individuals with Down syndrome were living at home, attending schools, and living in everyday society. This dramatically increased the IQs of people with Down syndrome, life expectancy to about 60, and many are educated and employed (14). This is outstanding progress that serves as a more extreme example of what is being done today; these children and adolescents should no longer be limited to confined classrooms and other settings where they are not integrated with the rest of society. There is clearly vast potential among these individuals that we need to expose and share with families and communities everywhere. This will be the real control that not only we should have, but that we can give to those with Down syndrome who have goals and desires of their own. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Conclusion<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white; line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; It is clear that individualized methods alone are not helping children with Down syndrome reach their full potentials, and that viewing them as having a developmental disability will only hinder their abilities. This group-based intervention will help change that stigma and make the population realize that they can be integrated into normal school systems and be treated with the same amount of respect and knowledge. The initial push is beneficial for them when they are younger, but parents and families must feel more optimistic about their lives. Integration and acceptance into society will provide that guidance for all individuals with Down syndrome to reach new limits and accomplish more than anyone thought they could. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">REFERENCES<o:p></o:p></span></b></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(1)Buckley SJ. Developing the speech and language skills of teenagers with Down <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; syndrome.&nbsp;<i>Down Syndrome Research and Practice</i>. 1993; 1(2): 63-71. <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(2) Connolly, B., Morgan, S., Russell, F., &amp; Fulliton, W. A Longitudinal Study of <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Children with Down Syndrome Who Experienced Early Intervention <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Programming. <i>Journal of the American Physical Therapy Association. </i>1993; <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 73(3): 170-179. <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(3) McLeod, S. Maslow’s Hierarchy of Needs. <i>Simply Psychology.</i> 2014. <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp; </span><a href="http://www.simplypsychology.org/maslow.html"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">http://www.simplypsychology.org/maslow.html</span></a><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"> <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(4) Natoli, J., Ackerman, D., McDermott, S., &amp; Edwards, J. Prenatal diagnosis of <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Down syndrome: A systematic review of termination rates (1995-<o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2011).&nbsp;<i>Prenatal Diagnosis,</i>&nbsp;2012; 32: 142-153.<o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(5) McLeod, S. Cognitive Dissonance. <i>Simply Psychology.</i> 2014. <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><a href="http://www.simplypsychology.org/cognitive-dissonance.html"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">http://www.simplypsychology.org/cognitive-dissonance.html</span></a><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"> <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(6) Icek, A. The Theory of Planned Behavior. <i>Organizational Behavior and Human <o:p></o:p></i></span></div><div class="MsoNormal" style="background: white;"><i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Decision Processes. </span></i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">1991; 50(2): 179-211. <i><o:p></o:p></i></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(7) Langer, E.&nbsp; The illusion of control.&nbsp;<i>Journal of Personality and Social Psychology. <o:p></o:p></i></span></div><div class="MsoNormal" style="background: white;"><i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-style: italic; mso-fareast-font-family: &quot;Times New Roman&quot;;">2012; </span><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">311-328.<o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(8) Kliewer, C. <i>Schooling Children with Down Syndrome: Toward an <o:p></o:p></i></span></div><div class="MsoNormal" style="background: white;"><i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Understanding of Possibility.</span></i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;"> New York, NY: Columbia University, 1998. <i><o:p></o:p></i></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(9) Davidson, J. Jamie Foxx, Alec Baldwin among stars at Global Down Syndrome <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Gala. <i>The Denver Post. </i>2014.<i><o:p></o:p></i></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">(10) Donnelly, Gabrielle. Eva Longoria Parker: How I Feel about My Sister's <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Disability.&nbsp;<i>Mail Online</i>. Associated Newspapers, 2009. <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><a href="http://www.dailymail.co.uk/femail/article-1192356/Eva-Longoria-Parker-I-"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">http://www.dailymail.co.uk/femail/article-1192356/Eva-Longoria-Parker-I-</span></a><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">feel-sisters-disability.html. <i><o:p></o:p></i></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(11) <span style="background: white;">Jamie Foxx: Global Down Syndrome Foundation 2012 Quincy Jones Exceptional <o:p></o:p></span></span></div><div class="MsoNormal"><span style="background: white; font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Advocacy Award Recipient.&nbsp;<i>Global Down Syndrome Foundation</i>. 2012. <o:p></o:p></span></div><div class="MsoNormal" style="margin-left: .5in;"><a href="http://www.globaldownsyndrome.org/news-community/quincy-jones-exceptional-"><span style="background: white; font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">http://www.globaldownsyndrome.org/news-community/quincy-jones-exceptional-</span></a><span style="background: white; font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">advocacy-award-recipients/jamie-foxx-global-down-syndrome-foundation2012-quincy-jones-exceptional-advocacy-award-recipient/.<o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(12) Craig, R. Communication Theory as a Field. <i>International Communication <o:p></o:p></i></span></div><div class="MsoNormal" style="background: white;"><i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Association. </span></i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">1999; 9(2): 119-161. <i><o:p></o:p></i></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(13) Kalkhoff, W., &amp; Thye, S. Expectation States Theory and Research: New <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Observations From Meta-Analysis.&nbsp;<i>Sociological Methods &amp; Research,</i>&nbsp;2006; <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 219-249.<o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(14) Whitten, M. <i>The Story of Two Syndromes</i>. 2011.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="background: white; margin-left: .5in;"><a href="http://www.globaldownsyndrome.org/about-down-syndrome/the-story-of-two-syndromes/"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">http://www.globaldownsyndrome.org/about-down-syndrome/the-story-of-two-syndromes/</span></a><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"> <o:p></o:p></span></div><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Siegel, M. (Professor) Social and Behavioral Sciences: Challenging Dogma. Lecture <o:p></o:p></span></div><br /><div class="MsoNormal" style="background: white;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; conducted from Boston University School of Public Health, B</span>oston, MA, 2014.&nbsp;<o:p></o:p></div>Emily Maplehttp://www.blogger.com/profile/10711700934258818531noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-38718704490210631072015-01-23T11:57:00.000-08:002015-01-23T11:57:03.724-08:00WHO’s Tuberculosis Treatment Interventions in Developing Countries to Prevent Occurrence of Multi-Drug Resistant (MDR) and Extensive Multi-Drug Resistant (XDR) Tuberculosis - Jesse Huang<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">Introduction</span></b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">The recent tuberculosis (TB) epidemic has been a major topic in global infectious diseases being consistently recognized as one of the worlds deadliest communicable diseases (1,2). In the 2014 Global Tuberculosis Report, the World Health Organization estimates over 9 million new cases of tuberculosis and 1.5 million casualties resulting from TB complication in the year 2013 alone(2). Even with the numerous intervention programs, this number has been continuing to rise at a steady rate.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">Caused by the pathogenic bacteria <i>mycobacterium tuberculosis, </i>TB is very&nbsp; adaptive and infectious pathogen. With the rising overuse of antibiotics along with inadequate treatment management of medical staff, the prevalence of drug-resistant tuberculosis has increased tremendously ever since the first introduction of TB antibiotic treatment almost 60 year ago (3). </span><span style="font-family: Georgia, serif; line-height: 200%;">Multidrug resistant (MDR) and extensively drug resistant (XDR) tuberculosis are the result of mutations in the bacteria that make it resistant to certain antibiotic medications. Specifically, MDR tuberculosis is when the organism is resistant to one or more drugs while XDR TB, a much more serious type, is </span><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">when the organism is resistant to most major first-line TB drugs such as isoniazid, rifampin, fluoroquinoline, and at least one of three second-line drugs such as amikacin, kanamycin, or capreomycin (4).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">After first declaring tuberculosis as a global emergency in 1993, the World Health Organization (WHO) started implementing the Stop TB Strategy to reduce worldwide TB prevalence along with reducing the emerging problems of drug resistant TB (5,6). </span><span style="font-family: Georgia, serif; line-height: 200%;">DOTS, standing for Directly Observed Treatment Short course, is one of WHO’s main strategies for controlling tuberculosis. It contains five elements which are further explained below: government commitment, early detection, standardized drug treatment, consistent delivery of drugs, and monitoring results. These guidelines were made to provide clear objectives for its global intervention program against TB with the major hope to minimize case re-occurrence and reduce likelihood of future outbreaks of MDR and XDR tuberculosis (6).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><br /></div><div class="MsoNormal" style="line-height: 150%;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">The Directly Observed Treatment Short Course (DOTS)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.0pt; mso-para-margin-left: 1.0gd;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">The Five Components of DOTS*<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 24.0pt; mso-list: l2 level1 lfo1; mso-para-margin-left: 2.0gd; text-indent: 0in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">1. </span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">“Political commitment with increased and sustained financing”<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 21.0pt; text-indent: 21.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">- Government support in following through interventions and policies<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 24.0pt; mso-para-margin-left: 2.0gd;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">2. “Case detection through quality-assured bacteriology”<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 24.0pt; mso-para-margin-left: 2.0gd; text-indent: 20.95pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">- Increased use of diagnostic techniques to promote early detection of TB<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 24.0pt; mso-list: l0 level1 lfo2; mso-para-margin-left: 2.0gd; text-indent: 0in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">3. </span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">“Standardized treatment with supervision and patient support”<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 45.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">- Drugs are implemented according to standards to achieve maximum effectiveness and to prevent re-occurrence.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 24.0pt; mso-list: l0 level1 lfo2; mso-para-margin-left: 2.0gd; text-indent: 0in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">4. </span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">“An effective drug supply and management system”<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 21.0pt; text-indent: 21.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">- Consistent resources to increase recovery<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 24.0pt; mso-para-margin-left: 2.0gd;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">5. Monitoring and evaluation system and impact measurement<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 24.0pt; mso-para-margin-left: 2.0gd; text-indent: 20.95pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">- Making sure health intervention are regulated correctly<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.0pt; mso-para-margin-left: 1.0gd;"><br /></div><div class="MsoNormal" style="line-height: 150%; margin-left: 12.0pt; mso-para-margin-left: 1.0gd;"><i><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">*Obtained from the World Health Organization on 12/10/2014<o:p></o:p></span></i></div><div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">Critique of Current Public Health Interventions<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Different Sources of Drug Resistant TB</span></b><span style="font-family: Georgia, serif; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">The efficient management of an epidemic of any disease requires proper knowledge of the source of infection. This has frequently stemmed the question: “How does the majority of patients become infected with drug-resistant TB”. An infection of drug resistant TB can come from either transmission where drug resistant TB is obtained from another individual or self-acquisition where it is developed within an individual’s own body. Recently, self-acquisition has been the major focus among intervention programs. Since drug resistant TB can be “created” from poor adherence to treatment and long ineffective use of medication, it has been a significant concern of health officials whether or not new MDR or XDR TB cases will emerge from improper distribution and control of antibiotic medication. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">In a 2005 research study conducted by Neel R. Gandhi, researchers surveyed rural South African hospitals to measure the impact of HIV on TB prognosis (7). During their observation, they found that a majority of XDR TB patients that were surveyed have never been previously treated for TB. This meant that most incidences of XDR TB were not likely self-acquired but obtained through transmission from another patient infected with XDR TB. Major concerns then came onto the possible outbreak of XDR TB through primary transmission especially in a susceptible population with a high prevalence of immunodeficient people where drug resistant TB is more likely to develop.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">In the DOTS intervention program, WHO focuses a significant amount of resources toward treatment management and follow-through to prevent the occurrence of self-acquired drug resistant TB. Two out of the five major components (Components 3-4) of DOTS’s intervention focuses on treatment management while there were no specifically designated component for preventing and controlling transmission of TB between patients (6). Although previous interventions that focused on self-acquired drug resistant TB had a significant role in reducing the occurrence of drug resistant tuberculosis, the result of Gandhi’s study in rural South Africa shows that most of the current drug resistant TB are from transmission and not through self-acquisition. Therefore, it would be resourceful to redirect much needed focus towards preventing TB transmission and to not focus entirely on TB treatment follow-through.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Problems with Follow Through of Antibiotic Treatment</span></b><span style="font-family: Georgia, serif; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">The current treatment plan for TB provides a significant challenge to proper public health intervention. As recommended by the CDC and WHO, the standard treatment regimen for tuberculosis is an initial two month treatment of isoniazid, rifampicin, ethambutol, and pyrazinamide followed by a second stage of treatment using isoniazid and rifampicin for another 4 months. The entire treatment procedure would often require six to nine months of commitment with numerous potential side-effects. This is not only difficult for the patient but also poses many financial limitation to public health intervention. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">Problems with TB treatment follow up is seen the most in low resource environments. These locations have a high rate treatment defaulting due mainly to insufficient resources for physicians to contact and monitor patients. Therefore, patients often stop or reduce treatment for long duration of time which is often a precursor to developing drug resistant TB. It is important to strengthen treatment monitoring programs to follow patients and successfully treat more TB patients to reduce spread and chances of MDR and XDR TB.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">WHO’s DOT program tries to improve follow up of its treatments through its belief of rigorous surveillance as stated below:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><i><span style="font-family: Georgia, serif; line-height: 200%;">“with rigorous monitoring of and accountability for ensuring cure... We believe that evidence and experience show that the only way to achieve these high cure rates on a programme basis is through direct observation of treatment given by a person accountable to the health system and accessible to the patient.”(WHO)(8)<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">However, this method of intervention can be a potential problem as it creates&nbsp; reactance in patients. Reactance is behavior theory where individuals will have the desire to do the opposite choice of what is given or demanded of them as an assurance of personal freedom (9). If patients are constantly watched and demanded to follow rigorous treatment procedure, they might feel that their freedom of choice is being taken away. Even though the treatment is benefiting the patient’s own well-being, discomforting treatment side-effects and the lack of understanding the dangers of TB can reduce willingness for patients to participate to the full extent necessary. Therefore, it would be better use an intervention that would be able to provide access to freedom and have them use their own free will to follow through treatment.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Early Detection Techniques</span></b><span style="font-family: Georgia, serif; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">Treatment of infectious disease is highly dependent on early detection. One important early detection method is contact tracing is the act of tracking and investigating previous contacts of an infected individual during their infectious period. It is relevant to tuberculosis surveillance because it is one of the most efficient methods of detecting early spreads of TB infection which improves treatment success rate. Current diagnostic tests for TB and drug resistance relies on mycobacterial cultures which can be expensive especially costly for low income and resource areas of the developing world. It is of great importance to find newer, faster, and cheaper ways of successfully diagnosing patients with the correct form of TB.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">As shown through its perseverance in history, tuberculosis is not an easy disease to control in a population. Due to it contagious and dormant qualities along with its already global spread, it takes a significant international effort to keep incidence rate manageable. In the current targets of the Stop TB Strategy, the WHO predicted that it would take at least 40 year to eliminate TB as a public health problem. Therefore, it is essential to implement not only short term interventions but also interventions with long term effects that will provide a much more powerful overall investment.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">WHO’s current tuberculosis program focuses significantly on direct intervention methods such through expensive antibiotic drug treatments and sometimes unreliable follow up procedures. With a significant investment of direct treatment, early detection techniques such as contact tracing as discussed would be a valuable intervention tool. Although very powerful when implemented, many of these intervention are very costly and only result in short term effects with no significant long term use.A common concept in both medicine and in public health is “An ounce of prevention is worth a pound of cure” (13). As a long term investment, prevention through social intervention could prove to be more efficient and far less costly when compared to direct intervention. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;"><b><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">Potential Public Health Intervention Methods</span></b><span style="font-family: Georgia, serif; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Infection Control and Isolation in Health Care<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">Since many of the current drug resistant TB are transmitted and not acquired through incomplete treatment as shown by the Gandhi’s study, it is important to invest resources into infectious disease control and prevention. TB is a highly contagious disease being able to become airborne simply through coughing or even speaking (5). There a number of effective methods to deal with airborne infectious diseases such as by implementing the wearing of surgical masks or reducing accessibility to crowded community structures. However, it is important consider that many TB patients are located in rural undeveloped countries were there already are wide spacing between individuals. Therefore to deal with TB transmission, it is important to intervene at its source, hospitals.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">Since the turn of the century, hospital environments has been a major source of TB outbreaks especially in developing countries. Heavy TB patient crowding, lack of proper ventilation, and poorly-sanitized operating conditions of some rural hospitals create an incredibly dangerous breading ground for TB. Following with the often poor drug adherence in these areas, many TB outbreaks in hospitals or clinics such as the MDR and XDR outbreak incidence in South Africa during March 2008 are drug resistant TB (10).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">To combat hospital TB transmissions, one of the most suggested interventions is to promote immunological and infection control education to first-line health care provides such as doctors and nurses along with medical administrative staff. Doctors and nurses have the quickest and most frequent access to patients. Therefore, well-organized educational seminars can provide long term investment to reduce not only TB infection but other hospital-related infections. Along with doctors and nurses, medical administrative staff should be especially encouraged to be involved in infection control. Since many administrator control over funding and construction projects, getting the knowledge of proper disease control in a hospital setting could be long term benefit to the proper management of hospitals.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">Continued education interventions has has numerous successes. In the US, hospital-acquired infections are an ongoing problem tackled by surgeons and the post-surgical staff with over a 10 billion dollar financial burden each year to the US health care system (11). This burden has been tackled through workshops and seminars that teaches physicians the various methods of infections and develop new techniques to prevent them.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Redirect treatment emphasis and </span></b><span style="font-family: Georgia, serif; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">An integrative intervention method to combat the current problem of follow up requires two steps . First, it is important to implement the right ratio of funding for treatment and follow up. Following from the discussion of “all or nothing”, lets consider two intervention methods. The first method places more emphasis on TB treatment and attempts to treat 100 people. The second method places more following through each TB treatment and attempts to treat only 20 people. If we assume that 10% of people follow through in intervention one and 50% followed through in intervention two, the resulting number of recovered TB patients would be the same. However considering how many people&nbsp; Therefore, the point of this illustration is that it would be more resourceful to treat fewer people with higher success rate than to treat more people with a lower success rate even if the end is the same number of recovered people.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">From our first intervention, there would be an decrease in the number of available treatment. The second intervention is complement of the first intervention by creating an application pool. It is important to visualize the association of treatment and results for TB to determine the method of intervention. In a broad view, treatment of TB is an “all or nothing” situation. It is necessary for patients to follow the duration of treatment plan for the patient to fully recover. If dropped out of treatment, the patient is likely to redevelop TB and be infectious. Therefore, any form of service or treatment provided to individuals that do not follow through will potential be wasted. In actuality, the “all or nothing” statement is not entirely true since patients who took TB medication and did not follow through are likely to develop drug resistant TB which is more difficult to treat in the future and can cause further transmission of MDR and XDR TB to others.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Marketing and Focusing on Immunodeficient Groups</span></b><span style="font-family: Georgia, serif; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">A potential social intervention to prevent cases of tuberculosis is to expose young children and school programs to the proper techniques in preventing disease transmission. As social cognitive theory suggests, individuals often learn through social context and observation (15). Young children are often the most susceptible to this theory and will most likely provide more effective results. In this intervention, school student would be taught at an early age to wash hands, cover up coughs, or wear surgical masks when sick. Marketing campaigns such as posters and basic sanitary equipment are potentially important tools to introduce proper prevention of disease transmission.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">The practicality of this social theory can be seen in the recent cultural changes of certain Asian countries. In Japan, wearing surgical masks has become a standard for people who are sick or have symptoms of coughing or sneezing. The habit which is often learned at an early age has become so deeply embedded in Japanese culture that it is constantly enforced through pressures of social conformity (15).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: Georgia, serif; line-height: 200%;">Additional benefits to the early exposure of daily sanitation techniques, children can become more knowledgeable about the role of health care providers. In many developing countries of Africa, many TB patients refuse treatment from doctors and hospital due to fear and misrepresented images of health care workers. This has been seen significantly in the recent Ebola epidemic where individuals infected with the deadly Ebola virus would hide and prevent themselves from being quarantined and treated by health care professionals. By introducing children consistently to the positive image of the hospital environment and health care workers, it would likely improve the general image of health care to the population at risk for TB potentially increasing future participation in TB treatment and supporting earlier diagnosis. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><br /></div><div align="center" class="MsoNormal" style="line-height: 200%; tab-stops: 347.5pt; text-align: center;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Conclusion<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; tab-stops: 347.5pt; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; tab-stops: 347.5pt; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: Georgia, serif; line-height: 200%;">Using Complementing Long-Term Social/Behavior Interventions</span></b><span style="font-family: Georgia, serif; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: 21.0pt;"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">The DOTS program has had many accomplishments since its initiation in 2006 having treated millions of tuberculosis patients world-wide(6). Although the DOTS program provided an essential springboard towards the management of TB treatment in developing countries, m</span><span style="font-family: Georgia, serif; line-height: 200%;">any direct intervention methods such as importing antibiotics and implementing expensive testing methods creates significant self-limitation to its own intervention’s availability and applicability. </span><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia, serif; line-height: 200%;">Considering the staggering costs of Stop TB Strategy and DOTS program, the current TB management is very time consuming and resource draining to WHO and many supporting organizations and countries. The solution is to direct portion of the funds towards long term investment. Many of the potential interventions discussed in this article such as infectious control education and health awareness in youth provide a much longer lasting effect than direct intervention. Direct interventions are necessary and has been an important effort in stopping the immediate spread of TB, but it is important to think about the long run and properly invest in long-term invention methods to complement ongoing direct interventions.<o:p></o:p></span></div><div align="center" class="MsoNormal" style="text-align: center;"><b><span style="font-family: Georgia, serif;">References<o:p></o:p></span></b></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">1. New Jersey Medical School: Global Tuberculosis Institute. A History of Tuberculosis Treatment. http://globaltb.njms.rutgers.edu/tbhistory.htm<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">2. World Health Organization. Global Tuberculosis Report 2014. xii<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">3. Mayo Clinic. Tuberculosis Causes. http://www.mayoclinic.org/diseases-conditions/t uberculosis/basics/causes/con-20021761<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">4. Centers for Disease Control and Prevention. Multidrug-Resistant Tuberculosis (MDRTB). Tuberculosis Fact Sheet http://www.cdc.gov/tb/publications/factsheets/ drtb/mdrtb.htm<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">5. National Institute of Allergy and Infectious Diseases, Tuberculosis http://www.niaid.nih.gov/topics/tuberculosis/Understanding/history/pages/historical_killer.aspx<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">6. World Health Organization, The Stop TB Strategy<o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">http://www.who.int/tb/strategy/stop_tb_strategy/en/<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">7. </span><span style="font-family: Georgia, serif;">Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U, Zeller K, Andrews J, Friedland G. Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet. 2006 Nov 4;368(9547):1575-80.</span><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;"><o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal" style="margin-left: 0in; mso-list: l1 level1 lfo3; text-indent: 0in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt; mso-fareast-font-family: Georgia;">8. </span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">Thomas R Friedena, John A Sbarbaro. World Health Organization. Promoting adherence to treatment for tuberculosis: the importance of direct observation. http://www.who.int/bulletin/volumes/85/5/06-038927/en/<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">9. Silvia, P. J. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology, 27, 277-284.<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">10. IRIN. SOUTH AFRICA: Prison-like hospitals for drug-resistant TB patients.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">http://www.irinnews.org/report/77447/south-africa-prison-like-hospitals-for-drug-resistant-tb-patients<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 11.0pt; mso-bidi-font-family: Georgia; mso-bidi-font-size: 9.0pt;">11. Goodman, Brenda. Health Day Reporter. US News. Five most common health care-associated infections strike 440,000 U.S. patients each year. http://health.usnews.com/health-news/news/articles/2013/09/03/hospital-acquired-infections-cost-10-billion-a-year-study<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,serif; mso-bidi-font-family: Georgia;">12. Centers for Disease Control and Prevention. Tuberculosis (TB). Tuberculosis Treatment http://www.cdc.gov/TB/topic/treatment/default.htm<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: Georgia, serif;">13. Benjamin Franklin. Good Reads.<o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;">http://www.goodreads.com/quotes/247269-an-ounce-of-prevention-is-worth-a-pound-of-cure<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: Georgia, serif;">14. Baseel Casey. Why do Japanese people wear surgical masks? It’s not always for health reasons. Japan Today. http://www.japantoday.com/category/lifestyle/view/why-do-japanese-people-wear-surgical-masks-its-not-always-for-health-reasons<o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: Georgia, serif;">15. Frank Pajares. Emory University. Overview of Social Cognitive Theory<o:p></o:p></span></div><br /><div class="MsoNormal"><span style="font-family: Georgia, serif;">and of Self-Efficacy http://www.uky.edu/~eushe2/Pajares/eff.html<o:p></o:p></span></div>Emily Maplehttp://www.blogger.com/profile/10711700934258818531noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-2500993618418775862015-01-23T11:54:00.002-08:002015-01-23T11:54:23.272-08:00A Social and Behavioral Critique on the Above the Influnce Campaign- Bianca Di Chiaro<div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Introduction</span></b><span style="font-family: &quot;Georgia&quot;,serif;">: <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The use of marijuana in adolescents is a public health problem of national importance because the number of smokers has been on the rise since the 1990s (1). &nbsp;The National Youth Risk Behavior Survey (YRBS), which is conducted every two years providing data from 9<sup>th</sup>through 12<sup>th</sup> grade students, showed that some drug trends have begun to increase. The survey showed that more students have used marijuana one or more times, have used marijuana on school property one or more times, and have been offered, sold or been given drugs on school property between 2009 and 2011. (2) The rising use of marijuana amongst peers can be linked to adolescents decrease in perceived risk of using the drug. (3) It is imperative that there is a public health focus on marijuana use in adolescents since their age group is more susceptible to addiction. (4)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; In response to the increased drug use by adolescents in the United States, the National Youth Anti-Drug Media Campaign was funded. (5) From 1998 to 2004 the United States Congress spent over one billion dollars towards the campaign. (6) The main focus of the campaign was to decrease drug use by educating, decreasing initiation, and convincing users to stop.&nbsp; (7) The current campaign is called Above the Influence, which targets adolescents with national messaging through television, print, and the internet. Much of the campaign focuses on commercials against the use of marijuana. One of the most frequently aired Above the Influence commercials is a thirty second commercial in which an adolescent who is high on marijuana is greeted in their kitchen by their dog. The dog tells the adolescent how they wish they didn’t smoke pot and that they are not the same when they are high. &nbsp;&nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; While the National Youth Anti Drug Media Campaign was able achieve high levels of media coverage the intended message did not reach the targeted youths. Instead, many of the youths created parodies of the commercial which can been seen all over the internet. Not only did the message have the intended effect, the amount of coverage caused the opposite to occur. The exposure decreased the youth’s intentions to stay away from marijuana and decreased the antidrug social norms affiliated with marijuana (6). Had the campaign focused on the social and behavior effects the commercial would evoke, the overall goals of the campaign would have been more successful. In the subsequent paragraphs the main problems with the commercial used during this campaign will be discussed. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; mso-outline-level: 1;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Critique: Ineffective use of the Health Belief Model<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The health belief model is a psychological model developed to predict health behaviors in individuals. The model first came about when a doctor wanted to better understand why many people were not taking advantage of free tuberculosis testing that was available to them. The Health Belief Model is used as a predictive tool for behaviors such as life style behaviors, life style behaviors in relation to health, and compliance with medication. An assumption that this model makes is that individuals will engage in specific health behaviors if the outcome is favorable to them. (8)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">There are six components of the health belief model, which were not effectively used&nbsp; to create behavioral change in the targeted youth of the Above the Influence campaign. The first component of the model is perceived susceptibility, which demonstrates an individual’s perception of their risk of developing the health issue. (8) In the commercial, the use of marijuana is not displayed as a health risk. Not displaying the health risks results in the targeted youths believing that marijuana is not a major cause of health problems. The second component is perceived severity, which demonstrates an individuals belief of the level of harm the health issue would cause if the individual were to develop it. (8) Many youths do not perceive marijuana use as harmful (3) and the commercial does not demonstrate the health risks involved with smoking marijuana to achieve the behavioral change. The next component is the perceived benefits. This component focuses on how changing an individuals habits would have a health benefit to them. (8) While the goal of the campaign is to show the benefits of not using or stopping the use of marijuana, the campaign falls short because the commercial demonstrates that if a person gets high they will have the benefit of talking to their dog. The forth component is the perceived barriers, here the model focuses on the obstacles an individual would face to maintain the beneficial health outcome. The commercial does not display the negative outcome of using marijuana only the positive outcome of communicating with their dog. The fifth component of the theory are the cues to action. This component is based on continual stimulation to increase the likelihood that the healthier choice would be made. Continual exposure to the commercial makes marijuana seem like the common social norm cuing the viewer into action to partake in drug use. The last component focuses on self-efficacy, an individual’s confidence in their ability to demonstrate the change. While a youth has the self-efficacy to decide to take action, not taking drugs may not be the action that they are willing to take. (9) <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The three main goals of the campaign are to decrease drug use by educating, decreasing initiation of those who have never smoked, and convincing youths who do smoke marijuana to stop (7). Instead of reaching these goals to deliver a healthy drug free message the commercial sends the message that if a person gets high they will be able to have communications with their pet dog. It can be expected that many youths with pets would want the opportunity to speak with their dog. The commercial could have been more successful in translating their message into a behavior if they had examined the effects of social and behavioral models. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; mso-outline-level: 1;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Critique: The Psychological Reactance Theory<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The psychological reactance theory is a psychological theory developed to explain the reaction that occurs when an individuals &nbsp;freedom of behavior is threatened or eliminated. The theory describes that an individual has a set of behaviors that they can display at any moment within the realm of possibilities.&nbsp; In preparation of choosing their next behavior, an individual takes in their internal and external surroundings. After taking in their surroundings, the individual weighs which behavior would bring them the most satisfaction in that moment. When one of their behaviors is threatened or eliminated the individual feels the loss of their freedom. The perceived loss of freedom causes reactance in the individual. Reactance is the reaction that occurs due to this loss causing the individual to attempt to reestablish their freedom of choice. (10) The Above the Influence commercial created by the National Youth Anti-Drug Campaign causes reactance in the targeted youth because the commercial threatens a behavior. The message of the Above the Influence commercial is to not smoke marijuana and to those who do smoke, to stop smoking marijuana. &nbsp;The message is thus eliminating this behavior choice. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">One of the main goals of the campaign is to focus on the youth that are already participating in smoking marijuana and convincing them to stop. Those that are already actively smoking marijuana or have previously smoked will feel the most reactance towards the message of commercial. The magnitude of reactance that is felt by an individual depends on the worth of the behavior to the individual. The greater the behavior is to the individual the greater the magnitude of reactance. The youths that are actively participating in smoking marijuana will have the greatest reactance towards the Above the Influence commercial.&nbsp; A smaller magnitude of reactance will occur in those who have not smoked marijuana or have only smoked a small number of times. The youth may not feel the reactance right away but when they feel their freedom of choice challenged they will have an even stronger will to reestablish their freedom. The reestablishing of their freedom occurs when they partake in the behavior that was threatened or partaking in a similar behavior such as smoking cigarettes. (10) The youths will be pushed towards the behavior that was threatened. This means that youths who have never smoked may start and those who do smoke will smoke more. The campaign is creating the opposite effect then the desired behavioral change. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">Another aspect that plays a role in the magnitude of reactance is similarity.&nbsp; When there is similarity between the individual and what the individual is observing, studies have shown a decrease in the negative force of reactance and an increase in the positive force of compliance. (11) In the commercial, a dog delivers the main message of the National Youth Anti-Drug Campaign. A dog and adolescent are not similar. Having a dog deliver the main message only increases the negative force of reactance in the youth. In this aspect the commercial pushes the targeted population further away from compliance with the main message of the campaign. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The psychological reactance theory creates a motivational state (10), where the youth may not have thought about wanting to try marijuana but the ad brings the behavior into their mind. This behavior is then threatened or eliminated from, in turn motivating them to take action against the commercial. The commercial makes the targeted youth believe that their peers are using marijuana, which increases the&nbsp; increases the likelihood that they should also smoke marijuana (6) Here a youth who may have never considered smoking marijuana may now have the intent to do so. The more times the youth is exposed to the commercial the more reactance they will feel. The psychological reactance theory may be able to explain why the intent to stay away from marijuana decreased during the time after the Above the Influence commercial campaign. (12)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; mso-outline-level: 1;"><b><span style="font-family: &quot;Georgia&quot;,serif;">Critique: The Social Cognitive Theory <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">The social cognitive theory is a psychological theory that was developed to explain how environmental factors, personal factors, and human behavior interact. The theory is used to describe how an individual gains knowledge through direct observation. &nbsp;The media plays an important outlet where individuals can observe and learn different behaviors. Through the media, individuals can observe both an action and the consequences while maintaining the sequence of events that led to behavior and outcome. Observations can motivate an individual to act despite whether there is a positive or negative reaction following the behavior. Through the Above the Influence commercial, the targeted youth observe someone their age who is high from smoking marijuana. The youth gains knowledge of the behavior and learns the outcome, which in the commercial is hearing their dog talk to them. Observing the commercial motivates the targeted youth to perform the behavior instead of avoiding the behavior. (8)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;There are three core determinants of the social cognitive theory that can effect an individuals behavior. The first determinant is based on an individuals understanding of the expected outcome. The individual develops an expected outcome through gaining knowledge of the risk related to the behavior. This knowledge can then create the condition for change. (8) In the Above the Influence commercial, the behavior that changed was not the goal of the campaign since a study found that youths were less likely to stay away from marijuana following the message. (12) The youth watching the commercial observes someone around their age, who is high and listening to their dog talk to them. The youth then understands that if they act the behavior of smoking marijuana their expected outcome is to talk to their dog.&nbsp; The second determinant is perceived self- efficacy and the third determinant is goals. This describes that an individual must have the skills necessary for change and believe they can make the change. Roles models can be factor that effects these determinants. Applying these two determinants to the commercial, the youth see someone their age, high and realize that they have the ability to get high and obtain the same outcome. (8)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,serif;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; There are key concepts to the social cognitive theory that can effect the main factors responsible for change. The first concept is expectations; the anticipated outcome of the behavior. In the commercial the only focus is on the outcome of smoking marijuana instead of focusing on the benefits of not smoking. Another concept is behavioral capability; having the skills to perform a behavior. With the widespread reach of the Above the Influence campaign, many youths observe others their age getting high. The observation creates the illusion that if their peers can get smoke marijuana then they also have the ability to smoke marijuana. Another concept of this theory is reinforcement, which is demonstrated by the wide spread media campaign. The commercial creates the idea that smoking marijuana is more common among youth and their peers increasing the likelihood of the behavior (12). Two other concepts of this theory is modeling and observational learning. In the Above the Influence commercial the targeted youth observes someone their age getting high. The youth gains knowledge of what it looks like to be high as well as gaining of knowledge from someone within their age group. Many of the concepts that effect behavior, as described through the social cognitive theory, caused an opposite effect of the main goals of the Above the Influence campaign. (8)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; mso-outline-level: 1;"><b>Proposed Intervention: <o:p></o:p></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;">Changing the Above the Influence campaign to include social and behavioral theory will increase compliance of the National Youth Anti-Drug Campaigns message. The main media source for the message would remain on television since this outlet creates observation learning with high sensation-value contexts. Studies show that messages geared towards older teenagers and young adults are most persuasive through television. (1) A commercial that shows a group of youths lead by a celebrity refusing to smoke marijuana, the commercial then shows the group off having fun playing soccer while the individual who offered the drugs is alone with anxiety. The use of a celebrity is critical because the use of someone famous has been shown to increase compliance with the health message. (14) The use of a similarly aged group as the targeted youth is used since adolescents are more likely to demonstrate behaviors similar to their peers (15). Instead of just stating the smoking marijuana is bad, the commercial shows the risks creating a larger impact (12) and demonstrating the benefits of saying no.<o:p></o:p></div><div class="MsoNormal" style="line-height: 200%; mso-outline-level: 1;"><b>Solution: Health Belief model<o:p></o:p></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;">The first critique of the Above the Influence commercial addressed social and behavioral problems explained through the health belief model. This theory describes that if there is a serious enough threat to someone’s health, that person will avoid the action. (8) In the Above the Influence commercial there is no threat to the youths health even though the main message is to not smoke marijuana. A better direction to take the commercial is to develop media that shows the health risk and severity that can be relatable to the youths. (16) A successful campaign that targeted youths to stop smoking cigarettes was the “truth” campaign. This campaign showed that the risks described to youths to cause change had to be relatable to their everyday lives such as pregnancy and divorce. The campaign demonstrated that everyday risk factors had a larger impact then long term risk factors. They found that youths had no reaction toward the risk of death because to them the scary facts were not seen as a big deal. The “truth” campaign also realized that they needed to use a message other then “don’t”. (17) The “truth” campaign shows that more can be achieved through showing why not to do something instead of saying “don’t” do something. The message of the serious risks of smoking marijuana, such as losing friends or anxiety (13), should be delivered by someone relatable to the youth instead of using a dog. <o:p></o:p></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-indent: .5in; text-justify: inter-ideograph;">At the beginning of the paper, the different components of the health belief model were discussed in relation to the negative effects caused by the Above the Influence commercial.&nbsp; Here, the components will be discussed in relation to delivering the National Youth Anti-Drug message to achieve behavioral change in the targeted youths. To achieve perceived susceptibility, marijuana should be reintroduced as harmful to strengthen the social norm that drugs are not good. To achieve perceived severity, the commercial should focus on the commonality of the risk factors associated with smoking marijuana. To achieve perceived benefits, the focus should not be on avoiding health risks but on a positive outcome. A benefit must be something relatable, unlike talking to a dog. This could be spending time outside with friends, playing rigorous sports, or participating in other group activities. (11)&nbsp; To show that there are no barriers, the commercial should focus on groups of students staying away from drugs. Self-efficacy can be achieved through reaching youths through the campaign, verbal reinforcement and showing peers working together in the commercial to stay away from marijuana. The goal of the campaign can be met through a commercial, if the commercial uses the health benefit model to its advantage by studying the social and behavioral components associated with the model. <o:p></o:p></div><div class="MsoNormal" style="line-height: 200%; mso-outline-level: 1;"><b>Solution: The Psychological Reactance Theory<o:p></o:p></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </b>The second critique that was made about the Above the Influence commercial focuses on the psychological reactance theory. This theory is used to describe the reaction of an individual if their freedom of behavior is threatened or eliminated. In the commercial, the goal of the dog is to relay the message of not smoking marijuana. The campaign would have been more successful at delivering this message if the message did not threaten the freedom of behavior.&nbsp; This problem can be solved without changing the main message of the National Youth Anti-Drug Campaign. In changing the commercial, the goal is to deflect reactance and increase compliance. When a message threatens freedom of choice, there is a positive force to comply and a negative force to react. In many cases of reactance, the negative force is the more powerful force causing the reaction. The goal of the commercial should be to reduce the negative force so that it is equal or less then the positive force. Achieving this will increase compliance. (11)<o:p></o:p></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </b>The reduction of the negative force of smoking marijuana can be achieved through using similarity. Delivering the message by someone who the targeted youths relate too will increase the positive force to comply and decrease the negative force to react. In the current commercial, a dog delivers the message, which is not similar to the targeted youth. This difference increases the negative force to react and decreases the positive force to comply. (11) The commercial instead should have an adolescent who is similar to the targeted youth deliver the message because adolescents are influenced by their peers (15). This similarity would increase the positive force to comply while decreasing the negative force to react. (11) To create even more compliance, a person that many adolescents look up to such as a celebrity should be used. A celebrity that is around the age of the targeted youth from a band, movie or television show would further increase the positive force and decrease the negative force of reactance. (14) Using a celebrity would increase the positive force and decrease the negative force by influencing the perception of the magnitude of the threat to freedom. Making a few changes to the Above the Influence commercial, following the psychological reactance theory would create a higher rate of compliance among the targeted youth. <o:p></o:p></div><div class="MsoNormal" style="line-height: 200%; mso-outline-level: 1;"><b>Solution: The Social Cognitive Theory<o:p></o:p></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The third critique that was made about the Above the Influence commercial focuses on the social cognitive theory. This theory describes how different factors can cause behavioral change in an individual. The three core determinants of this theory were discussed above and will now be applied to make constructive changes to the campaign commercial. The first determinant is outcome expectancies (8). In the current commercial the outcome described is using marijuana to talk to a dog. Instead, the commercial should be changed to highlight the real effects of smoking marijuana. For example, the commercial could show that marijuana causes anxiety and loss of friends (13) creating the condition for change. The second and third determinant is perceived self-efficacy and goals. This part of the commercial should highlight the mechanism by which the goal of not smoking is achieved. The goal of not smoking marijuana should be delivered by a group of people that the targeted youth can relate to as to demonstrate that the youth can do it too. Using these determinants properly through a commercial can have a large effect on implementing change in an individual’s health practice (8). <o:p></o:p></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="color: #5f497a; mso-themecolor: accent4; mso-themeshade: 191;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Changing the commercial to include some of the key concepts of the social cognitive theory can have a large impact on behavioral change. The first concept is expectations. Instead of the expectation of getting high and talking with their dog, the youth should understand the negative expectations associated with smoking marijuana. Another concept is behavioral capability. In the commercial the targeted youth observes someone who is similar to them being high. This demonstrates that they have the ability to get high too. Instead, the commercial should focus on someone who is similar to the youth not getting high. The commercial could demonstrate other activities with the person refusing to get high. The message of not smoking would be able to reach the youth because they would know they have the ability to refuse to smoke marijuana. Having the same widespread media impact as the Above the Influence campaign already has would create reinforcements of the positive message. The two other concepts of this theory are modeling and observational learning. Using someone his or her age to model refusing to smoke marijuana is more relatable then using a dog to deliver the campaigns message. This also gives the opportunity for the targeted youth to learn through observation. Making small changes based on the concepts and core determinants of the social cognitive theory would have a large impact on the compliance of the targeted youth.&nbsp; (8)<o:p></o:p></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><b>References: <o:p></o:p></b></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;"><br /></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">1. Palmgreen P, Donohew L, Lorch E, Hoyle R, Stephenson M. Television campaigns and adolescent marjijuana use: tests of sensation seeking targeting. <i>American Journal of Public Health</i>. 2001; 91(2):292-296<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">2. Centers for Disease Control. <i>Trends in the Prevalence of Marijuana, Cocaine, and Other Illegal Drug Use National YRBS</i>. Washington, DC: Centers for Disease Control <o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">3. National Institute on Drug Abuse. <i>DrugFacts: High School and Youth Trends. </i>National Institute of Health. http://www.drugabuse.gov/publications/drugfacts/high-school-youth-trends<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">4. Chambers RA, Taylor JR, Potenza MN. Developmental neurocircuitry of motivation in adolescences: a critical period of addiction vulnerability. <i>American Journal of Psychiatry </i>2003; 16(6):1041-1052<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; tab-stops: 13.5pt; text-indent: -.5in;">5. Office of National Drug Control Policy. <i>National Youth Anti-Drug Media Campaign. </i>Washington, DC: The White House. http://www.whitehouse.gov/ondcp/anti-drug-media-campaign<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">6. Hornick R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the National Youth Anti-Drug Media Campaign on Youths. American Journal of Public Health. 2008; 98(12): 2229-2236<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; tab-stops: 13.5pt; text-indent: -.5in;">7. Office of National Drug Control Policy. <i>Above the Influence Factsheet. </i>Washington, DC: The White House. http://www.whitehouse.gov/sites/default/files/page/files/ ati_fact_sheet_6-26-12.pdf<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">8. Theories and Applications (pp14) In: Theory at a glance: A guide for health promotion practice. National Cancer Institute, 2005<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">9. &nbsp;Behavioral Change Models. The Health Belief Model. Boston, MA: Boston University. http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models2.html<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">10. Burke W, Lake DG, Paine JW. Organization Change: A Comprehensive Reader.&nbsp; San Francisco, CA. 2009<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">11. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance (pp227-284) In: Silvia PJ. <i>Basic and Applied Social Psychology</i>. Greensboro, NC: Lawrence Erlbaum Associates, Inc., 2005.<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">12. Hornik R, Yanovitzky I. Using Theory to Design Evaluations of Communication Campaigns: The Case of the National Youth Anti-Drug Media Campaign. <i>University of Pennsylvania ScholarylyCommons</i> 2003. <i>&nbsp;</i><o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">13. National Institute on Drug Abuse. <i>Marijuana: Facts Parents Need to Know</i>. National Institute of Health. http://www.drugabuse.gov/publications/marijuana-facts-parents-need-to-know/want-to-know-more-some-faqs-about-marijuana<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">14. Cram P, Fendrick M, Inadomi J, Cowen M, Carpenter D, Vijan S. The Impact of a Celebrity Promotional Campaign on the Use of Colon Cancer Screening. <i>Arch Internal Medicine. </i>2003; 163(13): 1601-1605. <o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">15. Gardner M, Steinberg L. Peer Influence on Risk Taking, Risk Preference, and Risky Decision Making in Adolescence and Adulthood: An Experimental Study. <i>Developmental Psychology. </i>2005; 41(4)625-635<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">16. Edberg M. Individual health behavior theories (pp35-38) In: Edberg M<i>. Essentials of health behavior: Social and Behavioral Theory in public health</i>. Sudbury, MA: Jones and Bartlett publishers, 2007.<o:p></o:p></div><div class="MsoNormal" style="margin-left: .5in; text-indent: -.5in;">17. Hicks JJ. Tobacco Control. <i>The strategy behind Florida’s “truth” campaign. </i>Miami, FL: Crispin, Porter, and Bogusky, 2001.<o:p></o:p></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal"><br /></div><br /><div class="MsoNormal"><br /></div>Emily Maplehttp://www.blogger.com/profile/10711700934258818531noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-15671929952447850612015-01-23T11:53:00.000-08:002015-01-23T11:53:08.024-08:00A Solid Effort Falls Short in Addressing Youth Sexual Risk in Ottawa, Canada – Julia Bond<div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="font-family: Georgia, serif;">According to the Public Health Department in the city of Ottawa, Canada, the rates of sexually transmitted infections (STIs) such as chlamydia, gonorrhea, and HIV are on the rise among Ottawa’s young people. In an attempt to address this, Ottawa Public Health launched an intervention titled “Sex it Smart” (1). This program allows Ottawa residents to order 1 package of condoms to be mailed to their home address free of charge. The program website also contains a condom locator, which provides the addresses of locations where residents can pick up free condoms. This list includes health clinics, non-profit organizations, and some private businesses. Additionally, the website contains educational messaging around STIs. Though this intervention has many positive aspects that increase its chances of success, including being effectively branded with a logo, there are nonetheless aspects that need improvement.</span><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in;"><b><span style="font-family: Georgia, serif;">A Distanced Tone Invites Psychological Reactance and Modeling Behavior</span></b><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="font-family: Georgia, serif;">The “Sex It Smart” campaign homepage states, “Not using a condom is the top risk factor among individuals diagnosed with an STI...That’s why we launched Sex It Smart, a new condom campaign for youth.” There is also a scrolling banner at the bottom of the homepage that states “Think of all the qualities you want in a partner….is one of them Chlamydia?” These statements contribute to a feeling of significant separation between the “we” behind the campaign and the “you” to whom it is addressed that pervades the campaign’s website (1). Creating this distinction in the campaign’s messaging could result in 2 specific negative responses from young people when they engage with the campaign, which would significantly decrease its chances of success. <o:p></o:p></span></div><div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="font-family: Georgia, serif;">First, the separation between the public health workers who created the campaign and the young people they are trying to reach could incite psychological reactance. Psychological reactance is a phenomenon described by J.W. Brehm (2) in which people faced with a threat to their freedom respond by immediately taking steps to restore that freedom. A relevant example would be a parent forbidding their teenager from attending a party, and the teenager subsequently reasserting their freedom by sneaking out to the party that night. Studies have demonstrated that when it comes to messages that contain a threat to freedom (eg you must always use condoms), similarity of the messenger to the recipient of the message can significantly decrease reactance compared to a dissimilar messenger (3). The disparity between the messenger and the young people being addressed in the “Sex It Smart” campaign website could result in psychological reactance because young people will be made to feel as if their freedom to choose not to use condoms is being threatened. This will undermine the effectiveness of the campaign, as youth will subsequently seek to reassert their freedom to ignore the free condoms.<o:p></o:p></span></div><div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="font-family: Georgia, serif;">Secondly, the distanced tone of the campaign may influence youth behavior in an unintended way through social modeling. The campaign’s homepage references the following statistics about sexual health in Ottawa: “About a third of sexually active 15-29 year olds in Ottawa did not use a condom the last time they had sex. &nbsp;Fifteen to 29 year olds account for approximately three-quarters of 2013 chlamydia and gonorrhea diagnoses in Ottawa” (1). Social modeling theory posits that one way people adopt new behaviors is by mirroring behaviors observed in others in response to certain situations (4). Because the campaign has set up a distinction between the “us” behind the campaign and the “you” engaging with it, emphasizing the fact that a full third of youths did not use a condom while having sex could backfire and normalize the lack of condom use. If young people who are interested in having sex but who are naïve or inexperienced happen upon the site, instead of focusing on sexual health risks they may instead choose to focus on the fact that a large number of their peers who are successfully having sex are doing so without a condom. This in turn may influence their decision-making when they are faced with the opportunity to have sex. If, due to the perceived prevalence of not using a condom, they successfully have sex without a condom for the first time, social modeling behavior theory suggests that they will make the connection between not using a condom and effectively having sex, and they will likely continue to abstain from condom use (4). One examination of a failed youth-targeted anti-marijuana campaign that ran in the United States from September 1998 to June 2004 suggests this very phenomenon as one possibility for its failure. Hornik et al (5) state that exposure to the campaign messaging may have inadvertently implied that marijuana use was commonplace, thereby increasing the likelihood that young people exposed to the campaign would try it. The “Sex It Smart” campaign runs the risk of eliciting a similar boomerang affect by communicating to youths that many of their peers are having sex without condoms.</span><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in;"><b><span style="font-family: Georgia, serif;">Optimistic Bias Compounded by the Power of Partner Selection</span></b><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="font-family: Georgia, serif;">The above statistics referenced by the “Sex It Smart” campaign do demonstrate that there is a need to address youth sexual practices in Ottawa and attempt to rectify the large number of young people contracting STIs. Unfortunately, studies have demonstrated that people consistently underestimate the likelihood of negative outcomes happening to them. This phenomenon is known as optimistic bias, and has been demonstrated in a variety of populations, including active smokers (6, 7). Thus even though the statistics revealing the high risk of STIs among 15-29 year olds in Ottawa are compelling, it is likely that an individual reading them will underestimate their own personal risk. Additionally, studies have demonstrated that perceived controllability of a behavior increases the optimistic bias associated with that behavior (6). In the case of STI risk, people likely feel a large measure of control over their risk because they are the ultimate arbiters of their own sexual experience. Feeling that they control who their partners are will contribute to a sense of confidence that they are at less risk than other people. When optimistic bias is taken into consideration, the decision to highlight statistics on the homepage of the “Sex It Smart” campaign is a strategy that has the potential to undermine the campaign. If people don’t think that they personally are at risk, it is unlikely that they will seek out free condoms.</span><span style="font-family: &quot;Georgia&quot;,serif;"><o:p></o:p></span></div><div style="line-height: 200%; margin-bottom: .0001pt; margin: 0in;"><b><span style="font-family: Georgia, serif;">The fallacy of rational decision making in the heat of the moment</span></b><o:p></o:p></div><div class="MsoNormal" style="line-height: 200%;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">The “Sex It Smart” campaign improves upon the often-criticized health belief model because it acknowledges that everyone does not have equal access to condoms, and attempts to rectify that by providing them free of charge (8). Unfortunately, the campaign ends its efforts at getting condoms into the hands of young people, which suggests that the people who designed it believed that once people had condoms, they would then choose use them in the moment. This presumes that health-related decision making and behavior is the result of a rational, considered decision-making process, an assumption which has been demonstrated to be faulty in many situations (8). Designing the campaign to end with getting condoms to young people reduces its chance of being successful for a few reasons. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Firstly, it has been demonstrated that sexual arousal significantly affects decision-making. Especially relevant to this campaign, one study of college-aged males demonstrated that self-reported willingness to engage in unsafe sex was significantly higher when males were sexually aroused as compared to when they were nonaroused. Of particular importance is that fact that subjects were unable to predict the effect that being aroused would have on their own tolerance for unprotected sex (9). This study indicates that even if the “Sex It Smart” campaign were successful in getting a nonaroused person to obtain condoms, this does not mean that in an aroused state they would use them. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Further, a 2001 self-report study of almost 10,000 high school students across Canada revealed that alcohol use was an independent risk factor for inconsistent condom use (10). Alcohol has been demonstrated to affect women’s sexual decision making by increasing their perceptions of a situation as having sexual potential and increasing sexual interest, as well as potentially influencing women to focus more on the positive aspect of risk-taking behavior (11). Once again, in this context simply having condoms would not be sufficient to enable positive behavioral change. In order to be effective, this campaign needs to address the discrepancies between the initiative to obtain condoms and the drive to use them in the heat of the moment.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Secondly, the “Sex It Smart” campaign fails to address the role of gender in sexual decision making. In her astute criticism of the health belief model, L. Thomas decries the “…model’s inability to allow for the inclusion of the relationship between health status and historical, social, and political structures” (12).&nbsp; This lack of insight into the role gender of in sexual risk is present in the “Sex It Smart” communications. A recent study examining 15 Australian women who engage in non-romantic sex concluded that though these women may be partaking in “non-traditional sexual behavior,” (eg having sex outside of a committed relationship), they were nonetheless still constrained by traditional gender roles, and thus had limited sexual agency. The authors suggest that this is in part due to the limited availability of a social script that promotes empowered female sexual agency (13). These conclusions are borne out by an evaluation of the sexual attitudes of 161 women that demonstrated that despite initial assertiveness about condom use, even minor prompting from a male partner against condom use substantially reduced a woman’s likelihood to use a condom (11). In a survey of 24 English women between the ages of 16 and 20 who were about to have or had recently had an abortion, the women cited, among other reasons, a desire “not to break the spell” and pressure from a male partner, as reasons why they did not use condoms (14).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; When it comes to condom use, providing women with condoms is not sufficient to overcome the complex dynamics present in heterosexual sexual activity. These data suggest that despite being cognizant of the risks of unprotected sex, women often go along without using a condom, in part to please male partners. In order to more effectively increase condom usage among young women, initiatives need to empower women as sexual decision makers, and increase their perceptions of self-efficacy in sexual negotiation (15). Unfortunately, the “Sex It Smart” lacks compelling messaging addressing these issues.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Clearly, an initiative that provides condoms with the assumption that they will be used when young people are in the midst of a complex sexual negotiation is erroneous. The calm, level-headed person who orders the condoms from the “Sex It Smart” campaign website thinks differently than the aroused person who will subsequently opt not to use them. In order to truly be effective, the “Sex It Smart” campaign needs to take pains to go beyond providing condoms and attempt to exert some influence over decision making during sexual activity.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Introducing We Sex It Smart – Uniting Youth for Healthier Sex<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; In order to address the above flaws in the “Sex It Smart” campaign, a new campaign called “We Sex It Smart” could utilize the existing framework of free condom distribution but add components that would increase its chances of success. “We Sex It Smart” would be a youth-directed movement designed by young people themselves, and feedback from the target audience would be frequently solicited. “We Sex It Smart” would be branded as a movement to promote better, healthier sex, as opposed to being limited to reducing STI transmission. “We Sex It Smart” would house personal stories on its website, highlighting people brave enough to be open about their own experience with STIs. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">To increase relevance during sexual activity, “We Sex It Smart” would add a ritualistic component to the free condoms. Condoms would come with stickers that could be gifted to partners or placed in sticker books that would come with orders of condoms. There would be a variety of stickers to encourage a “collect them all” attitude. Partners would be encouraged to create a joint sticker book, thereby providing a level of camaraderie in sexual decision making. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Finally, “We Sex It Smart” would host forums, discussion boards, and branded informational material on its website that would directly address the reality of sexual decision-making for young people. These areas would be called “We Ladies Sex It Smart,” and “If you sip, don’t slip,” and would be branded as distinct components of the “We Sex It Smart” campaign to increase memorability and impact. These message boards would openly acknowledge the fact that young people are often making sexual decisions while under the influence of alcohol, and would allow young people to share their own experiences. &nbsp;There would also be educational material addressing female sexual agency and healthy decision-making even while drinking.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Striking the right tone for youth behavioral change</span></b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">To address the issues associated with the current tone of “Sex It Smart,” “We Sex It Smart” would engage with youths from its conception to ensure that the tone of the campaign does not invite psychological reactance. As demonstrated by Silvia, similarities between the messenger and the audience reduce the risk of psychological reactance to messages that could be perceived as limiting freedom (3). To that end, using young people themselves to communicate the about the risk of STI transmission during unprotected sex will decrease the chance that other young people will react negatively to the information. Additionally, it has been demonstrated that designing public health campaigns with youth input and featuring youth leadership is exceptionally effective in inciting behavioral change. As described by Bauer, the “Truth” campaign in Florida had a significant effect in reducing youth smoking in the state. The hallmark of this campaign is that it is led by young people and relies heavily on the input of young people who are peers of the target audience (16). “We Sex It Smart” will borrow from this model, and thereby seek to put youth front and center in the quest to increase healthy sexual decision-making. The rebrand of the campaign to encompass healthy sexuality, as opposed to simply addressing STI risk, is also an effort to increase youth engagement. People are generally not moved by messaging and campaigns that only focus on health. Rebranding this campaign to focus on broader themes like autonomy, intimacy, and pleasure will help keep young people interested and engaged (17).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Making young people the face of the “We Sex It Smart” campaign will also address any concern with social modeling behavior. The campaign will no longer center on unhealthy adolescent sexual behavior, but rather will celebrate healthy sexual decisions. This will encourage youths looking to the campaign for information on sexual behavior to associate condom use with positive sexual outcomes </span><span style="font-family: Georgia, serif;">(4)</span><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Personal Stories as an Antidote to Optimistic Bias</span></b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">“We Sex It Smart” will focus on the voices of young people – even those who have made risky sexual decisions in the past. According to “the law of small numbers,” people tend to be biased towards remembering and relating to individual stories as opposed to broad statistics (18). Additionally, it has been demonstrated that messages that are emotionally evocative and tell compelling personal stories are the most impactful, and have the most potential to incite behavioral change despite optimistic bias (19). To this end, “We Sex It Smart” will leverage the law of small numbers by highlighting the emotionally charged stories of people who have been affected by STIs in the past to encourage youth to recognize that anyone can be affected by them. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Due to the sensitive nature of STI status, “We Sex It Smart” could use the stories of adults who have since overcome their battles with STIs such as chlamydia and gonorrhea. Adult women who have had fertility struggles due to contracting these STIs in their youth would be particularly compelling for the campaign. These women could share emotional stories that would drive home the fact that despite perceived control over sexual decisions, it is impossible to know who has an STI. It would also help dispel any stereotypes that youths have as to who contracts STIs, as it has been demonstrated that in addition to perceived control, an existing stereotype of who is at risk is associated with optimistic bias (3). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Rituals and Empowerment to Encourage Relevancy in the Moment<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Bridging the gap from the acquisition of condoms in a cold state to the actual use of condoms in an aroused state is likely the biggest challenge facing the “We Sex It Smart” campaign. This challenge is compounded by the addition of alcohol and gender dynamics into the equation. The “We Sex It Smart” campaign will have 2 components that will work together to attempt to address this issue.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Firstly, the addition of a ritual can make a behavior more likely to be adopted (18). To capitalize on this, the “We Sex It Smart” campaign will add a ritual to condom use to make it easier to remember, even in a state of arousal. Condoms obtained through the “We Sex It Smart” campaign will come with stickers attached to them. These stickers will be branded to match the campaign. The promotional messaging on the campaign website will encourage participants to use these stickers in one of a few recommended ways: 1) post it in public to show support for your campaign, 2) share them with friends or partners, or 3) put them in sticker booklets that are provided with orders of condoms. As a variety of stickers will be produced, these sticker booklets could encourage condom usage by making a game out of collecting the stickers. The option to choose which activity to do with your sticker would provide another layer of ownership over the ritual, which could increase individual investment (18). The sticker booklet will come emblazoned with promotional messaging encouraging participants to share stickers with their partner. This will attempt to make condom use a joint activity, which may deflect some of the gendered tension that has been reported in heterosexual sexual activity (13-15).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Secondly, “We Sex It Smart” will add forums and informational material that will help youth accurately address their sexual realities. For one thing, the role of alcohol in sexual decision-making is completely absent from the “Sex It Smart” messaging (1). “We Sex It Smart” will address alcohol as a component of young peoples’ lives, and contextualize healthy sexual decision-making within a social life that includes alcohol use. This aspect of the campaign will have its own brand, called “If you sip, don’t slip.” Branding can make a public health campaign more effective and memorable, and a critical component of branding is to acknowledge the reality of the target audience (20). “If you sip, don’t slip” will openly address the fact that adolescents sometimes make sexual decisions under the influence of alcohol (10), and would provide information on how alcohol affects sexual decision-making and suggestions for making healthy sexual decisions even in a state of inebriation. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">“We Ladies Sex It Smart” would be another branded component of the “We Sex It Smart” campaign. This effort would focus entirely on young girls and empowering them to have sexual agency. It would openly acknowledge that oftentimes girls report feeling more embarrassed than boys purchasing condoms, and this directly impacts their usage patterns (21), and also that girls react to the influence of male partners when it comes to condom usage (11). “We Ladies Sex It Smart” would provide empowering messages to young girls around their ability to influence sexual decisions and speak up for their desires. It would also provide a forum where young women could share their experiences and encourage each other to speak up for healthy sexual experiences. This could contribute to positive modeling behavior. If young girls are exposed to women who have advocated for healthy sexual behavior in their own lives, it could create new social norms that empower girls to push for condom use if they want, even against the wishes of their male partner. Since women are reported to be struggling from the absence of a positive social script that ascribes them sexual agency (13), it will be up to “Ladies Sex It Smart” to create it.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Conclusion<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">The “Sex It Smart” campaign is strong start for an effective public health initiative. It strives to address one of the crucial problems in public health: access. By providing condoms to anyone in Ottawa who fills out an online form, it makes a laudable attempt to eliminate barriers to sexual health in a community that needs it.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">Regardless, the campaign has many aspects that should be improved to maximize its efficacy and reach. For one thing, effective public health campaigns must work with their target audience, not speak down to them. Harnessing the energy and voice of Canadian youth would be a boon to this effort. Secondly, the use of statistics is not a compelling way to encourage change. Instead, this effort should use individual stories to make its message more relevant. Finally, the assumption that improving condom access is sufficient to improve condom usage misses much of the reality of sexual decision making. The addition of a fun ritual, as well as the open acknowledgement of some of the realities of adolescent sexual life in Canada, would make this campaign far more relevant, engaging, and effective.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;">References</span></b><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 200%;"><o:p></o:p></span></div><div class="MsoListParagraphCxSpFirst" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: Georgia, serif; font-size: 12pt;">Ottawa Public Health. <i>Sex It Smart Campaign</i>. Ottawa, Canada. Ottawa Public Health. </span><a href="http://www.sexitsmart.ca/"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">www.sexitsmart.ca</span></a><span style="font-family: Georgia, serif; font-size: 12pt;">.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: Georgia, serif; font-size: 12pt;">Brehm J. A Theory of Psychological Reactance (pp. 277-290). In: Burke W, Lake DG, and Paine JW, ed. <i>Organization Change: A Comprehensive Reader</i>. San Francisco, CA: Jossey-Bass, 2009.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: Georgia, serif; font-size: 12pt;">Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. <i>Basic and Applied Social Psychology</i> 2005; 27:277-284.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: Georgia, serif; font-size: 12pt;">DeFleur ML, Ball-Rokeach SJ. <i>Theories of Mass Communication</i> (5<sup>th</sup> edition), Chapter 5 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: Georgia, serif; font-size: 12pt;">Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. <i>American Journal of Public Health</i> 2008; 98:2229-2236.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: Georgia, serif; font-size: 12pt;">Weinstein ND. Unrealistic optimism about future life events. <i>Journal of Personality and Social Psychology. </i>1980; 39:806-820.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">7.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. <i>JAMA</i> 1999; 281:1019-1021.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">8.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Individual health behavior theories (chapter 4). In: Edberg M. <i>Essentials of Health Behavior: Social and Behavioral Theory in Public Health</i>. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">9.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Ariely D and Loewenstein G. The heat of the moment: the effect of sexual arousal on sexual decision making. <i>Journal of Behavioral Decision Making</i>. 2006; 19(2):87-98.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">10.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Poulain C and Graham L. The association between substance use, unplanned sexual intercourse and other sexual behaviours among adolescent students. <i>Addiction</i>. 2001; 96(4):607-621.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">11.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp;&nbsp; </span></span><!--[endif]--><span lang="FR" style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-ansi-language: FR; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Norris J, Stoner SA, Hessler DM, et al. </span><a href="https://www.blogger.com/null" name="citation"><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Cognitive mediation of alcohol's effects on women's in-the-moment sexual decision making.</span></a><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;"> <i>Health Psychology.</i> 2009; 28(1):20-28.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">12.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. <i>Journal of Professional Nursing</i>. 1995; 11:246-252.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">13.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Moran C and Lee C. Women’s constructions of heterosexual non-romantic sex and the implications for sexual health. <i>Psychology &amp; Sexuality</i>. 2014; 5(2):161-182.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">14.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Brown S and Guthrie K. Why don't teenagers use contraception? A qualitative interview study. <i>Eur J Contracept Reprod Health Care</i>. 2010; 15(3):197-204.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Georgia; mso-fareast-font-family: Georgia;">15.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Pearson J.</span><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial;">Personal Control, Self-Efficacy in Sexual Negotiation, and Contraceptive Risk among Adolescents: The Role of Gender. <i>Sex Roles</i>. 2006; </span><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">54(9-10):615-625.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">16.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial;">Bauer UE, Johnson TM, Hopkins RS, Brooks, RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000.</span><span style="background: white; color: #333333; font-family: &quot;Arial&quot;,sans-serif; font-size: 8.0pt;"> </span><i><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial;">JAMA </span></i><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial;">2000; 284:723-728.</span><span style="font-family: Georgia, serif; font-size: 12pt;"><o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">17.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial;">Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 2.” Boston University. SB712. Fall 2014. September 11, 2014.</span><span style="font-family: Georgia, serif; font-size: 12pt;"><o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">18.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial;">Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 13.” Boston University. SB712. Fall 2014. December 4, 2014.</span><span style="font-family: Georgia, serif; font-size: 12pt;"><o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">19.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. <i>Am J Public Health. </i>2009; 99(12):2217-2223.<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">20.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial;">Siegel, Michael. “Social and Behavioral Sciences SB271 – Session 9.” Boston University. SB712. Fall 2014. October 30, 2014.</span><span style="font-family: Georgia, serif; font-size: 12pt;"><o:p></o:p></span></div><br /><div class="MsoListParagraphCxSpLast" style="margin-left: 0.75in; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family: Georgia, serif; font-size: 12pt;">21.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">&nbsp; </span></span><!--[endif]--><span style="background: white; color: #333333; font-family: &quot;Arial&quot;,sans-serif; font-size: 8.0pt;">&nbsp;</span><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Moore SG, Dahl DW, Gorn GJ, Weinberg CB. Coping with condom embarrassment.</span><span style="background: white; color: #333333; font-family: &quot;Arial&quot;,sans-serif; font-size: 8.0pt;"> </span><i><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;">Psychology, Health &amp; Medicine.</span></i><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;"> 2006; 11(1):70-79.</span><span style="background: white; color: #333333; font-family: &quot;Arial&quot;,sans-serif; font-size: 8.0pt;"><br /></span><span style="font-family: &quot;Georgia&quot;,serif; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-fareast-font-family: &quot;Times New Roman&quot;;"><br /><!--[if !supportLineBreakNewLine]--><br /><!--[endif]--><o:p></o:p></span></div>Emily Maplehttp://www.blogger.com/profile/10711700934258818531noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-24397177830884275502014-12-18T14:00:00.001-08:002014-12-18T14:00:28.137-08:00Critique of the “Don’t Be a Lab Rat” Campaign-Xiaohui Cao <div class="MsoNormal"><b>Introduction</b><br /><b><br /></b>The “Don’t Be a Lab Rat” campaign, launched August 2014, is a marijuana-education campaign focusing on teens in Colorado. The $2 million campaign is created by the state of Colorado and the city of Denver, and founded by legal settlements with pharmaceutical companies.<br />The “Don’t Be a Lab Rat” campaign includes a website, interactive theater ads and TV commercials. Besides, 12-foot-long, 8-foot-high rat cages are used at the corner of street in Denver to raise teens’ attention on marijuana use. The campaign’s online website has a lot of statistics on adverse effects of using marijuana in teens. The TV commercials also suggest that marijuana impairs teens’ brain and causes long-term mental problems. By using disputed facts, the campaign want to warn the teens not to be a lab rat in finding the adverse health effects of the drug.<br /><br />Marijuana use by adolescents has been a problem in the US for a long time. According to the National Institute on Drug Abuse (1), marijuana use among teens has been increasing since the mid-to-late 2000s. In 2013, 7.0 percent of 8th graders, 18.0 percent of 10th graders, and 22.7 percent of 12th graders used marijuana in the past month. Also, studies have shown that drug abuse could lead to other problem behaviors such as fighting, stealing, vandalism, and early sexual activity. Therefore, effective anti-drug campaigns targeting on adolescents are important to decrease the prevalence of drug use in this population. However, the “Don’t Be a Lab Rat” campaign has been controversial since it was created. In this paper, the flaws of this campaign will be discussed and new intervention will be proposed.<br /><br /><b>Part One: Critique Arguments</b><br /><br /><b>Argument one: Scare tactics do not work well on teens</b><br />The most obvious flaw the “Don’t Be a Lab Rat” campaign makes is that the campaign relies heavily on scare tactics such as fear-based statistics. On the website of the campaign dontbealabrat.com, there are a lot of scary statistics from research that connect marijuana use to high risk of certain disease such as schizophrenia, depression, stroke, heart attack and etc. The website also emphasizes the negative effects of the drug on the teens’ brain, saying that marijuana could shrink parts of the teenage brain and that teen marijuana users may lose an IQ of 8 points permanently. In addition to the scary statistics, the campaign also put giant human-sized “lab rat cages” all over Colorado, trying to warn teens to stay away from experimenting such adverse health risks. However, it is shown that teens are less likely to believe the message and tend to discredit the messenger when exaggerated dangers, false information are delivered (2).<br /><br />These threatening statistics and “lab rat cages” are used by the campaign with regard of the Health Belief Model. Health Belief Model, developed in the 1950s, argues that individuals are ready to change their health behavior if they believe that they are susceptible to the condition and the condition has serious consequences (3). By using the model, the campaign is intending to raise the teens’ awareness of severity of the outcomes and simply assuming that the teens will realize the terrible consequences of smoking drug and thereby stay away from it. However, the Health Belief Model may not work very well on teens because its limitations under the condition.<br />One assumption the campaign makes is that teens are rational so that they will weigh their degree of risk and analyze the cost-benefit of their behavior and make the right decision to stay away from drugs (4). However, the reality is that individuals may not be rational thinking when making decisions (5). &nbsp;This is especially true when it comes to teens. For example, one study shows that “a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making” (6). In the campaign, teens may be aware of all the adverse effects of marijuana might have on their health but still use the drug. One theory that might suitable for this case is the Optimistic Bias Theory. According to optimistic bias theory, individuals tend to underestimate their own risk of having a bad outcome in the future (7). &nbsp;For example, one study shows that optimistic bias is linked to sexual risk taking in youth (8). In the “Don’t be a lab rat” campaign, teens may think they are invulnerable to the adverse effects, and such optimistic expectations make the fear-based statistics ineffective.<br /><br />Also, health may not be a strong core value appealing to teens. The “Don’t Be a Lab Rat” campaign focuses on raising the teens’ awareness of adverse health effects of using marijuana. It emphasizes the relationship between teenage marijuana use and risks of many serious diseases such as schizophrenia, depression, stroke, and heart attack. Unfortunately, teens may in fact have less care about their health. In other words, health is not a strong core value for this particular population. In advertising theory, it is important to know what your target audiences really want and need. If health is not the most important value teens have been seeking, it is less likely that raising awareness of health would work in the campaign.<br /><br /><b>Argument two: Psychological reactance is created among the teens</b><br />Another reason why the “Don’t Be a Lab Rat” campaign is flawed is that it may introduce psychological reactance among the teens through wrong messages and wrong messagers. According to psychological reactance theory (9), when people are told to do something or not to do something, they think their freedom is threatened or lost. As a result, they will experience a motivating pressure towards reestablishing their threatened freedom by doing the things that they are told not to do (10). When teens see the slogan of the campaign “Don’t be a lab rat”, they may think their freedom is being taken away because they are asked not to use the drug. In order to reform their freedom, teens will instead begin to use marijuana, which is the opposite of behavior that the campaign suggests. Therefore, exposing to the campaign may in fact motivate their willingness to initiate using of marijuana rather than keeping them away from the drug.<br /><br />Also, the campaign incorrectly uses “researchers” as their messagers to deliver the message that using drug is bad for teens. Psychological reactance could arise because such authoritative messagers have little in common with the teens and therefore are less persuasive. This disconnection between teens and messagers would make it hard for messagers to successfully persuade teens to stay away from marijuana.<br /><br /><b>Argument three: Failing to account for social norms</b><br />The third reason why the campaign is considered flawed is that it only focuses on the change of individual teens’ behaviors to using marijuana rather than taking into account the effect of social norms, which is another limitation of the Health Belief Model (4). Health Belief Model is most suitable for one time decision such as getting a flu shot. When coming to the decision of quitting from drug, HBM may not work in such a complex condition where other factors involved. Instead, drug use is the outcome of the interaction between intrapersonal factors and social factors such as influence from peers and parents (5). In this situation, social norms theory is more proper to use since it emphasizes the importance of understanding environment and interpersonal influences in changing behaviors in teens.<br /><br />According to the Social Norms Theory (11,12), misperceptions of how peers think and act will influence teens’ behavior. When information on peer group norms is incorrectly present, teens are more likely to overestimate or underestimate the prevalence of the behavior among their peers. Usually, they overestimate the value of problem behaviors and underestimate healthy behaviors, tending to adopt the problem behavior (12). Studies have shown that American students usually misperceived the norms of their peers by perceiving considerably exaggerated drug use as typical at their school (13). This perceived norm is that the typical student is a much more frequent user than the self-reports indicated. Therefore, it is quite likely that in the “Don’t Be a Lab Rat” campaign, teens may incorrectly perceive a higher prevalence of marijuana use among their peers and thereby initiate using of the drug. In addition, if their peers who use the drug seem to be some cool guys, their likelihood of engaging in the drug may increase further. Based on the report of the National Survey On American Attitudes On Substance Abuse Xvii: Teens (2012), 47% of teens who have seen pictures of their peers partying with alcohol or marijuana on social networking site such as Facebook and MySpace said that it seemed like the teens in the pictures were having a good time (14).<br /><br /><b>Part Two: Proposed Intervention</b><br />The “Don’t Be a Lab Rat” campaign seems to be flawed and ineffective because of the above reasons. Therefore, a more effective campaign that may be needed to reduce the prevalence of drug use among teens in Colorado. Three more effective approaches that address the above problems in the campaign are discussed below.<br /><br />First, to address the problem that teens do not concern much on health risks presented in the scary statistics, the campaign should use personal stories and focus on core values that are more important to teens. Second, in order to avoid or reduce psychological reactance, use similar messagers and positive message to make the messagers more persuasive and to make the message more compelling. Third, using Social Norms Theory instead of Social Belief model to account for environmental and interpersonal influences.<br /><br /><b>Defense one: Using stories instead of scare tactics</b><br />The first approach for the proposed intervention is to use personal stories instead of scary statistics. Based on the Optimistic Bias Theory, teens are likely to think their own risks of getting disease are lower than the present risks in the general population. Therefore, instead of using statistics that show risks of disease among the general population, the campaign could use personal stories to raise awareness. For example, put stories of their peers on the website and create videos with images and music. One thing need to be aware is that using health as a core value in the story seems to be ineffective. The campaign should do research and find values that their target audiences really want and use that value in their stories. For example, since most teens regard independence and freedom as important values, the story could be a peer losing independence because of using drug.<br /><br /><b>Defense two: Using similar communicators and positive messages</b><br />In order to avoid psychological reactance, the campaign should change their message to a more positive one and use communicators who are familiar and similar to the teens. For example, using peers, especially the most popular ones in school to deliver the message could better make the message persuasive. Popular peers are similar to and welcomed in the teens, and thereby will be more persuasive than researchers. Research suggests that similarity can increase the positive force toward compliance and decrease the negative force toward resistance (15). Also, studies show that similarity increases the likelihood of compliance by increasing liking for the communicators (16). In addition to change of communicators, the campaign should also change their message to one that makes teen feel their freedom is ensured rather than threatened.<br /><br /><b>Defense three: Telling the truth and creating sense of belonging</b><br />To address the problem where teens are likely to overestimate the prevalence of marijuana use in their peers and engage in using the drug, correction of misperception is needed. Studies have shown that correction of the misperception could reduce prevalence of certain problem behavior (17). One possible way to correct the misperception is to let individuals know the actual healthier norms. This is based on the power of the Social Norms Theory, which indicates that social norms could influence people in both unhealthy and healthy ways (12). When individuals have a perception that most people do not use drugs, they will also less likely to use drugs. Therefore, rather than presenting a lot of unreliable information on potential dangers of marijuana and unintentionally making them perceive an overestimated prevalence of drug use, the campaign should show teens the truth -- accurate information about the actual healthier norms among their peers. For example, the campaign could do surveys to find out the teens’ perceived prevalence of marijuana use among peers and the actual normative prevalence, and then show these figures to the teens.<br /><br />Another approach to account for peer influence on drug use among teens is to create sense of association and belonging. This could be done through branding and creating an identical logo for the campaign. In order to make the teens join and embrace in their campaign, the Florida’s “truth” campaign make “truth” a brand, successfully gaining wide awareness (6). The “Don’t Be a Lab Rat” campaign could also make their own brand similar to “truth” and create a cute and identical logo to let more teens join their campaign. Based on the Social Norms Theory, since teens are likely to be influenced by their peers, the campaign could also create sense of belonging through their online website and social networking site such as Facebook. Teens could join their peer group online, share their positive experience and stories, and get positive feedbacks from their peers. If they see a majority of their peers are living a positive and healthy lifestyle, they will less likely to engage in an unhealthy behavior such as using drugs. Researchers have analyzed studies on college students’ binge drinking and found that web-based feedback could have a positive effect on the problem (18).<span class="Apple-tab-span" style="white-space: pre;"> </span><br /><br /><br /><b>References</b><br />1.<span class="Apple-tab-span" style="white-space: pre;"> </span>National Institute on Drug Abuse. DrugFacts: High School and Youth Trends. http://www.drugabuse.gov/publications/drugfacts/high-school-youth-trends<br /><br />2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Botvin GJ, Malgady RG, Griffin KW, Scheier LM, Epstein JA. (). Alcohol and marijuana use among rural youth: Interaction of social and intrapersonal influences. Addictive Behaviors 1998; 23: 379–387.<br /><br />3.<span class="Apple-tab-span" style="white-space: pre;"> </span>National Cancer Institute. Theory at a glance: a guide for health promotion practice. (2nd ed.) NIH Publication 2005; 05- 3896<br /><br />4.<span class="Apple-tab-span" style="white-space: pre;"> </span>Edberg M. Individual health behavior theories (pp. 35-49). In: Essentials of Health Behavior: Social jand Behavioral Theory in Public Health. Jones and Bartlett Publishers, 2007.<br /><br />5.<span class="Apple-tab-span" style="white-space: pre;"> </span>Dan A. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.<br /><br />6.<span class="Apple-tab-span" style="white-space: pre;"> </span>Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.<br /><br />7.<span class="Apple-tab-span" style="white-space: pre;"> </span>Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39:806-820.<br /><br />8.<span class="Apple-tab-span" style="white-space: pre;"> </span>Chapin J. It Won't Happen to Me: The Role of Optimistic Bias in African-American Teens' Risky Sexual Practices. Howard journal of Communications 2001; 12; 1: 49-59.<br /><br />9.<span class="Apple-tab-span" style="white-space: pre;"> </span>Brehm, JW. A Theory of Psychological Reactance. New York Academic Press, 1966. <br /><br />10.<span class="Apple-tab-span" style="white-space: pre;"> </span>Grandpre J, Alvaro EM, Burgoon M, Miller CH, Hall JR. Adolescent reactance and anti-smoking campaigns: a theoretical approach. Health Commun 2003;15; 3:349-66.<br /><br />11.<span class="Apple-tab-span" style="white-space: pre;"> </span>Berkowitz AD, Perkins HW. Problem drinking among college students: A review of recent literature. Journal of American College Health 1986; 35: 21-28.<br /><br />12.<span class="Apple-tab-span" style="white-space: pre;"> </span>Berkowitz AD. The Social Norms Approach: Theory, Research and Annotated Bibliography. Trumansburg, NY, 2003.<br /><br />13.<span class="Apple-tab-span" style="white-space: pre;"> </span>Bruce EC, Beth RH, Cynthia AG. Adolescent Development: Pathways and Processes of Risk and Resilience. Annual Review of Psychology 1995; 46: 265-293.<br /><br />14.<span class="Apple-tab-span" style="white-space: pre;"> </span>Perkins HW, Meilman PW, Leichliter JS, Cashin MA, Presley CA. Misperceptions of the Norms for the Frequency of Alcohol and Other Drug Use on College Campuses. Journal of American College Health 1999, 47:253-258.<br /><br />15.<span class="Apple-tab-span" style="white-space: pre;"> </span>National survey on american attitudes on substance abuse xvii: teens. http://www.casacolumbia.org/addiction-research/reports/national-survey-american-attitudes-substance-abuse-teens-2012<br /><br />16.<span class="Apple-tab-span" style="white-space: pre;"> </span>Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.<br /><br />17.<span class="Apple-tab-span" style="white-space: pre;"> </span>Byrne D. An overview of research and theory within the attraction paradigm. Journal of Social and Personal Relationships 1997; 14: 417–431.<br /><br />18.<span class="Apple-tab-span" style="white-space: pre;"> </span>Moreira MT, Smith LA, Foxcroft D. Social norms interventions to reduce alcohol misuse in university or college students. Cochrane Database of Systematic Reviews 2009; 3.<br /><br /></div>Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-86431152498817236802014-12-18T13:55:00.000-08:002014-12-18T13:55:31.538-08:00Primary Violence Prevention And Asking The Right Questions: Why School-based Interventions Fail To Change Behaviors – Sylvie Hundley<div class="MsoNormal" style="line-height: 200%;"><b style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">1.0 Introduction</span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">On an average day in the United States, sixty-five people die and more than 6,000 people are physically injured from interpersonal/intimate partner violence (9). In recent years this violence </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">seems to be occurring with greater frequency and severity in our society (2-3,9,15-17). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Intimate partner violence (IPV)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">, generally termed to encompass physical, sexual, or psychological harm by a current or former partner or spouse, (14) </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">is a growing public health concern that affects billions globally (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">2-3,9,15-17</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">1.1 Public Health, Psychopathology and Intimate Partner Violence <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Integrating the public health model for IPV prevention has caused a shift in the way we respond to violence from a reactive approach </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">to a preventative approach (2-3,6,9-10,12-13,15-17). Additionally, research on developmental psychopathology, supported by the National Institute of Health, has expanded our understanding of violence. Psychopathology studies have shown that adolescent and adult violent behavior almost always can be traced back to origins in early life. They have demonstrated with statistical accuracy that adolescent violence can be predicted from indicators demonstrated as early as five years of age (3). Public health and psychopathology studies indicate that the development of violent behavior is an interaction between cultural forces and failures in development. These studies support the popular belief that youth violence prevention is the most effective way to end IPV (3,9). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">1.2 Forming Prevention Programs: Focus On Youth Prevention<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">In the past two decades youth violence rates have stabilized suggesting that the problem is no longer an epidemic but instead has become endemic to our society (3). In response, scores of IPV intervention programs have been haphazardly assembled to squelch violent behavior. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Many prevention programs focus on interrupting the development of violent behavioral in youth before violence begins. (3,9). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">To c</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">apitalize on the adolescent “window of opportunity” for </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">learning and early intervention efforts, most primary prevention programs are conducted in middle school to high-school settings.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> While there is no universal model for IPV prevention, given the social and (usually) gendered nature of the problem most youth </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">programs</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> appear to be loosely based on social learning theory and feminist theory (3,6,11,15-17). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">1.3 Program Evaluation<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">In an attempt to find the cure-all program that can be implemented to end IPV, violence interventions have been rigorously analyzed for efficacy. Unfortunately Meta analysis of IPV prevention programs report that the overwhelming majority cannot demonstrate measurable outcomes (11,15-17). The few programs that do manage to document statistical significance report slight changes in in knowledge and attitudes among the intervention group. However, knowledge and attitudes are easier to change than behaviors (3) and there remain few effective adolescent IPV preventions available (11). Additionally, among some interventions the change in attitude was documented in the undesired direction (16,17). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">1.4 Asking “Why?”<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">This lack of efficacy is not surprising, given that IPV is not only pervasive in many communities, but also vastly underreported and often construed as a normal part of immature relationships (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">2-3,6,9-10,12-13,15-17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">. Despite the fact that our approach to eliminating IPV from society is broadening in scope under the public health lens, our response is still too reactionary and too focused on the violent outcome.&nbsp; This is demonstrated by the overwhelming attention placed on measuring program effectiveness instead of measuring the mediators of behavior change. It is crucial that programs measure the skills that intervention strategies intend to change in order to determine which changes in specific skills ultimately lead to changes in behavior. The goal should not only be determining which programs work, but to understand why (17).&nbsp; Public health has provided a bridge between conceptualization of how chronic violence develops and application of how prevention programs can interrupt that development. But in order to accurately implement prevention programs that work in the real world, their needs to be another bridge connecting the sciences, social theories and preventions to the public at large (3). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">2.0 Criticisms <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; There are three main elements of consideration that have not been properly evaluated in IPV primary prevention programs that inhibit substantial measures of behavior change.<b>&nbsp;&nbsp;&nbsp;&nbsp; <o:p></o:p></b></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">2.1 Missing The Critical Components Of Social Learning And Cognitive-behavioral Theories<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .25in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Almost all youth IPV prevention programs employ feminist and social learning theories as a basis for intervention. However, the extent to which interventions use critical components of these theories is unclear, especially social learning theory. Social learning and cognitive-behavioral theories emphasize the importance of identifying potential factors that influence the development of new skills in the adoption of new behaviors. However, few interventions examine the acquisition of previously absent behaviors as part of their intervention (11). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .25in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">2.1.1 Limited Setting and Social Learning Theory<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .25in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">It is clear that violence is a learned behavior any exposure to violence in early age is highly predictive of entering a violent relationship later in life (2-3,6,9-10,12-13,15-17). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Social learning theory acknowledging that learning does not happen in isolation of ones environment; stressing the importance of external influences on various internal processes. The theory postulates that a large contribution to behavioral development is the product of observing and then emulating the actions of others within an individual’s community (1). This is known as modeling. Modeling behavior is common among adolescents given the overwhelming need to attain peer acceptance and “fit in” with a group (1-3,6-7,11,14-17). School programs that focus on changing the nature of violence among peer-group interactions and peer-group norms can be extremely influential in behavior modification but programs of this nature are less common than individual approaches (2). Furthermore, just as peers and schools exert their own influence on behavior, so too do the other environments children inhabit and confront on a daily basis (2,11). For this reason, school-based IPV intervention programs that apply social learning theory in a “microenvironment” are inherently flaw. School-based programs for IPV interventions are isolating the school environment from the home environment and so create unrealistic circumstances that fail to address real-world situations, and fail to produce real-world results. Without connecting school-life and home-life school-based interventions are putting youth in opposition with their origin and limiting potential to influence behavior. It is important that school interventions do not come at the expense of parent-teen communication, mistrust, or conflict. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.1.2 Social Ecological Model and Excluded Populations<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif;">As youth might observe violence in their home, they may also look to the larger community to teach them about healthy relationships (8). To account for the multiple ways the environment influences youth behavior, </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">the CDC utilizes the social ecological model as a basis for IPV prevention initiatives. Similar to social learning theory, the social ecological model identifies the interactions between external and internal processes in the development of behaviors. The social ecological model conceives of relationships as operating on different levels: interpersonal, community, and society level (13). School interventions largely ignore community or population level interactions by focusing instead on individual choices (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">3,11,15-17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. The social ecological model proposes that there are multiple levels at which behaviors can be influenced. School-based interventions focusing on only one level of the model may be overlooking whole segments of the population. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Additionally, some students, especially those most at risk may not be accessible by schools (17) Many students may lack school engagement and/or have difficulty getting involved in school-related activities. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Many school-based interventions systems use a messy, one-classroom-at-a-time educational approach to IPV prevention. They usually bring in a speaker from outside of the community who addresses a class with an isolated, presentation about IPV (17). This approach can evoke strong psychological reactants. This has been demonstrated in some programs that reported</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;"> a “backlash” among the male population who developed attitudes in opposition to program messages (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">16,17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.1.3 Family Environment<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .25in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Social learning theory suggests that through teaching and shaping their children’s behavior, parents dramatically affect acceptance or rejection of acceptable behaviors (1) yet family venues have received relatively little attention in IPV prevention programs (17). This is surprising given the mounting evidence for the intergenerational predictors of violence. The popular notion of a cycle of violence suggests that witnessing partner violence or experiencing family violence at a young age is strongly associated with increased risk for children to develop attitudes, beliefs, and behaviors that lead to their own involvement in violent relationships (1-4,6-9,11-13,15-17). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .25in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.2 Universal Interventions and Limited Theoretical Approach. <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">School-based interventions appear to be advantageous for many reasons. They can easily reach large numbers of students in a short time, create safe environments, promote learning, and affect social interactions and peer modeling behavior. Most IPV interventions are universal, that is, they are directed towards one or only a few targeted skills, contexts, or persons without regard for risk or personal factors (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">3,11,15-17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. Although universal interventions are an excellent way to provide basic information to a large population, different people experience IPV in different ways (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">3,8-9,11,15-17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Studies show that IPV is a multidimensional problem that spans across a constellation of risks factors (2-4,6-9,11-13,15-17). Risks do not exist in isolation from one another; each uniquely contributes to the development of violent behavior and outcomes (3,17). The complexity of IPV require interventions to either focus simultaneously on multiple risk factors or target specific prevention efforts to specific children (3). Selective interventions allow for targeting of specific at-risk populations or environments, and thus the content of those interventions can directly address whatever risk factors are believed to lead to partner violence.&nbsp; Ultimately, the development of selective interventions requires a solid theoretical framework in order to identify the vulnerable population to target interventions (16,17). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.2.1 Narrow Focus On Theories <o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">The majority of IPV programs represent a fairly limited range of theoretical approaches (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">15,17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. &nbsp;</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">The </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">background-situation model of courtship aggression developed by Riggs &amp; Oleary, attachment theory, social expectations theory, and the social ecological model are all important behavioral theories that are largely underutilized by school intervention programs (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">3,11,15-17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.2.1a Background-Situational model<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">The background-situation model of courtship aggression takes into account the interaction background factors that may affect an individual’s tendency to be generally aggressive, and situational factors that result in the expression of partner violence. Background factors include modeling of antagonism by parents, parent–child aggression, prior use of violence, arousability, and certain personality factors. Situational factors include relationships conflict, stress, alcohol use, and partner aggression. In essence, background factors explain who might be involved with partner violence and situational factors explain when partner violence might occur (17). The background-situational model may be important for identifying specific variables as predictors of IPV.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.2.1b Attachment Theory<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Attachment theory focuses on cognitive formations of relationship processes. Attachment theory proposes that children conceptualize relationships based on their history with significant caregivers. The theory suggests that this cognitive-affective understanding of relationship elements, (the relationship, the self, and the other) functions both as a prototype and template for developing future relationships. Although cognition develops and changes over time, internal working models, which operate outside of awareness, are thought to remain generally consistent (16). Studies suggest that power, reciprocity, and intimacy are developmentally important for adolescents, their development of intimate relationships and violence within those relationships ( 2-4,6-9,11-13,15-17). Thus focusing on the role of coercive interactional processes in the development of IPV using Attachment theory may be beneficial. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">2.3 Multiple Risk Factors And The </span></b><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Lack Of Generalizability </span></b><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"><o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Studies show that dating violence begins in middle school and disproportionately affects minority groups yet there are minimal interventions that target this demographic (11,17). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Two school-interventions such as <i>Safe Dates and fourth R: Skills for youth Relationship (fourth R) </i>programs have been shown to produce significant behavioral effects: both reduced dating violence perpetration or victimization. However, these programs may not be as effective in ethnic-minority middle school youths because they were developed for and evaluated in older, predominantly White youths (11). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .25in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">There are a number of factors that contribute to keeping the interpersonal pattern of violence and aggressive behavior consistent over time. The emerging conceptualization is that chronic violent behavior results from life-course developmental experiences (3). The life-course perspective (18) helps to understand how the combination of early programing experiences at critical/sensitive life stages and the cumulative effect of lifetime exposure to IPV impacts individual’s risk and protective factors. Studies suggest that the source of violent behavior resides at the intersection of the individual and the culture interacting over time.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .25in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.3.1. Intergenerational cycles of IPV<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">The social learning model would predict that those who witness violence in their upbringing would be more likely to repeat behavior in their own relationships (1). Supporting the concept of modeling, several</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> studies have documented a relationship between witnessing violence in the home and increased risk of being both a victim and a perpetrator of violence. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Family risk factors, particularly those associated with parental behavior and the home environment are highly associated with IPV risk (1-4,6-9,11-13,15-17). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Youth who experience IPV report witnessing their parents exhibiting acceptance of abuse or engaging in violent relationships and perceive the abuse to be normal because they, “</span><span style="font-family: Georgia, serif;">grew up in an environment where that’s what they see people do.”(7, p.568).&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2.3.2 Cultural Competence<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: Georgia, serif;">Studies suggest that abuse is as a learned behavior in which cultural norms played an important role. Often parental acceptance or downplay of adolescent IPV was attributed to cultural beliefs that supported traditional gender roles and permissive attitudes toward violence. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Supporting feminist theory, studies find that adherence to traditional sex roles is among the most powerful predictor of attitudes supporting tolerance of IPV (7,17). The importance of underlying attitudes about sex roles, power, and control are strongly influenced by culture </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">(2,4,7,8). Studies show that across many Latino communities “gender roles </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">not only serve as a justification for abuse, but they also increase women’s vulnerability to abuse by keeping them isolated, subservient to male partner</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">s, and self-sacrificing to com</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">munity and family” (7, p.568)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> Additionally, </span><span style="font-family: Georgia, serif;">In some cultures abuse is not viewed as an issue. If the child is brought up in an environment where abuse is normal and the community says the abuse is within what they consider normal, then it becomes difficult, and possibly insulting to label their relationships as “undesirable.” </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">2.3.3 Adolescence<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">The adolescent life stage is a period of heightened risk for IPV given the developmentally distinct ways they experience violence (4,7). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Adolescents are highly susceptible to modeling behavior and tend to conform to rigid gender stereotypes and social norms. Adolescence is a period of value and identity formation as well as a time when youth are creating their ideas of love and attachment (</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">2-4,6-9,11-13,15-17)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-font-style: italic;">.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> Additionally, pubertal development and social influences aid in the formation of romantic interests and sexual motivations increasing sensation seeking, risk taking and reckless behavior. Taken together, the reorganization of regulatory systems that occurs in adolescents’ development and social influences shape the adolescent life stage as a critical period, tangled with both risks and opportunities (14)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; It may also be important to consider whether partner violence is merely one component of the characteristic risk-seeking behaviors that occur in adolescence. It may be that adolescent are “hard wired” to take risks of this nature because their brain is not fully developed (16,17). In this instance it is important for interventions to work on building an environments that are as safe as possible for adolescents to take risks. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">3.0 Conclusion: Bridging The Gaps<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">IPV prevention programs are still in early development, but are likely to be an important component of prevention strategies (2,3,6,9,11-13,15-17).&nbsp; Current primary prevention efforts for partner violence consist almost exclusively of universal, school-based, dating violence prevention programs that target individual-level factors. These programs show little variability with regard to theoretical foundations, intervention strategies, or targeted populations. Additionally, prevention programs fail to incorporate key components of the few models they do use by limiting interventions to school venues </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">(</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">3,11,15-17). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">School-based interventions need to find a community outlet (8) and incorporate a more accurate use of social learning theory (11) that acknowledges the differences between the home and school environments. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">More work is needed regarding program development to expand the theoretical basis for interventions, and to develop targeted and culturally sensitive interventions that understand the complex interactions of youth development and environmental influences. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Interventions that utilize these theories must be culturally competent and address the different ways that people may experience or be predisposed to violence. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"><o:p></o:p></span></div><div class="MsoBodyText" style="line-height: 200%;"><br /></div><div class="MsoBodyText" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">4.0 Proposed Intervention: Making IPV Prevention Programs “Sexy”<o:p></o:p></span></b></div><div class="MsoBodyText" style="line-height: 200%;"><br /></div><div class="MsoBodyText" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Given the nature of IPV, it is essential the intervention happen early. School-based interventions accomplish this goal, but they must have a structured curriculum that is supported by behavioral theories/models along with community-based activities. In order to yield the best overall outcomes for families impacted by IPV prevention programs must utilize a combination of outreach and collaborative strategies that are rooted in the community and connect to personal values. This can be accomplished with effective use of social marketing theory and advertising theory. <o:p></o:p></span></div><div class="MsoBodyText" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">4.1 Social Marketing And Advertising<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Social marketing and advertising theory have been growing in popularity within the public health arena (5). Social marketing theory is a way to create and package intervention programs so that it fulfills the needs of a target population’s wants. There are certain basic cultural values that are held in common and have a strong impact within community networks (5,7,17). Social marketing and advertising theory are able to create mass universal appeal for a product by offering desirable benefits that grab the attention of communities of interest. Programs that properly utilize these theories have been proven to facilitate the acceptance, rejection, modification, abandonment, or maintenance of particular behaviors by groups of individuals (5). Once a target population has been identified a combination of advertising theory, social expectations theory, and social networking theory can be used to effectively seed a campaign. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">4.1.1 Using Social Networks To Insert Desirable Behaviors<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Social expectations theory states that people will follow societal norms. Adolescents are especially susceptible to following cultural norms and so can be more easily persuaded using advertising theory. Social Expectations theory evaluates behavior on a population level, targeting social norms, as a predictor of how whole groups might behave. Social networking theory works as a means to focus interventions by mapping out out networks within groups. Understanding the social norms within one cluster of a social network and targeting that population with an effective use of advertising theory can effectively seed behavior changes that increase positive peer modeling, community endorsement of acceptable dating behavior, and social support for IPV prevention.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">In order to effectively package and sell anti-violence, IPV programs must conduct extensive marketing research with youth, their parents, and other influencers inside and outside school compounds (5). The social-ecological model can be used to better understand violence and the effect of potential prevention strategies. In considering the complex interplay between individual, relationship, community, and societal factors the social ecological model helps to address the dynamics that put people at risk for experiencing or perpetrating violence (13). <o:p></o:p></span></div><div class="MsoBodyText" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">4.2 The Notion Of Exchange<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">IPV intervention programs need to address deep desires, inspirations and aspirations of their young audience. Most programs assume that freedom from violence is a big enough promise to catch interests however, as adolescents is a time when many youth are still forming their ideas of love violence may not be a deterring factor for them. In fact, m</span><span style="font-family: Georgia, serif;">any service providers report that they found it difficult to get some youth to see that they were being abused in a relationship (7)</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">. Some adolescents may be so focused on “being in love” and belonging to someone that jealousy and possessive behaviors are often misinterpreted as signs of affection (2-4,7,11,15-17). Programs to target youth and their communities need to utilize advertising theory to create mass universal appeal for IPV prevention initiatives. This may involve celebrity endorsement or social media, which highlights the attractiveness of strong women and caring men. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">4.3 Researched Based Preventions, Targeting Interventions To Appeal To Core Values<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">It is important that vulnerable populations receive IPV prevention services specific to the unique way they perceive violence (2-9,11,15-17). This means evaluating core values specific to cultural identities to convey messages that will be well received by the target population (5). School-based universal interventions are missing their mark by assuming that education leads to prevention (5,17). The educational model believes that creating awareness is the best way to create behavior change. However, knowledge is not as strong of a core value as love and acceptance. The educational model works best works when the benefits of the behavior change are inherently attractive, immediate, and obvious and costs are low (i.e. SIDS campaign, educating parents to put baby to sleep on it’s back to prevent sudden infant death syndrome). In contrast, marketing is the most effective strategy when program goals are not directly consistent with self-internalized beliefs because it offers alternative choices that invite voluntary behavior exchange. Programs need to have a greater focus on selective interventions that allow for targeting of specific at-risk populations or environments. The content of those interventions can then directly address whatever risk factors are believed to lead to partner violence. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">4.3.1 Enforcing Freedom<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">It is important not to over generalize and apply labels. Message should reinforce freedom not take it away. In these way, IPV intervention programs need to give out positive stereotypes, avoid psychological reactants, and construct messages in a way that reinforces freedom not box people into categories. Using marketing gives IPV programs a brand, reinforces core values, and ensures sustained intervention (5). Marketing and advertising theory would ensure that messages are applicable to real-world environments and are delivered effectively. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">4.4 Taking Control<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Studies on IPV prevention have found that the community must take responsibility for ongoing program activities, and advertising theory is a way to get the communities interested in a campaign (5). Furthermore, the community must assume ownership of their campaign (8). This involves giving youth the ability to develop their own campaigns, create advertisements for their campaign, develop social networks, and ultimately enhance executive functioning and subconsciously change behaviors. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">5.0 Conclusion: A Call to Action<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">For an IPV prevention campaign to be successful, it must consist of a promise that provides a solution to issues that the target population considers important and offer a benefit they truly value. Promotional strategies must carefully design a specific message using appropriate communication techniques that resonate within communities. Community-based preventions that utilize marketing theory have the potential to harness community strengths by facilitating mobilization, empowerment, and participation, balances power differentials which ultimately benefit social changes (5). <b><o:p></o:p></b></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">References:<o:p></o:p></span></b></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><!--[if supportFields]><span style='font-size:12.0pt;line-height:200%;font-family:"Georgia","serif"'><span style='mso-element:field-begin;mso-field-lock:yes'></span>ADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY <span style='mso-element:field-separator'></span></span><![endif]--><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%;">1. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Bandura A. SocialLearningTheory. General Learning Corporation; 1971. p. 1–41. <o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">2. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Dahlberg L. Youth Violence in the United States Major Trends, Risk Factos, and Prevention Approaches. Am J Prev Med. 1998;14(4):259–72. <o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">3. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Dodge K a. The science of youth violence prevention. Am J Prev Med [Internet]. 2001 Jan;20(1):63–70. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0749379700002750<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">4. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Goff HW, Shelton a J, Byrd TL, Parcel GS. Preparedness of health care practitioners to screen women for domestic violence in a border community. Health Care Women Int [Internet]. 2003 Feb [cited 2014 Nov 19];24(2):135–48. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12746023<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">5. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Grier S, Bryant C a. Social marketing in public health. Annu Rev Public Health [Internet]. 2005 Jan [cited 2014 Dec 1];26(9):319–39. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15760292<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">6. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Jaffe PG, Reitzel D, Killip SM. An Evaluation of a Secondary School Primary Prevention Program on Violence in Intimate Relationships. 1992;7(2). <o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">7. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Kulkarni SJ, Lewis CM, Rhodes DM. Clinical Challenges in Addressing Intimate Partner Violence (IPV) with Pregnant and Parenting Adolescents. J Fam Violence [Internet]. 2011 Aug 21 [cited 2014 Nov 9];26(8):565–74. Available from: http://link.springer.com/10.1007/s10896-011-9393-1<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">8. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Moya EM, Chávez-Baray S, Martinez O. Intimate partner violence and sexual health: voices and images of latina immigrant survivors in southwestern United States. Health Promot Pract [Internet]. 2014 Nov [cited 2014 Nov 24];15(6):881–93. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4216606&amp;tool=pmcentrez&amp;rendertype=abstract<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">9. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Mercy J a., Rosenberg ML, Powell KE, Broome C V., Roper WL. Public health policy for preventing violence. Health Aff [Internet]. 1993 Nov 1 [cited 2014 Nov 25];12(4):7–29. Available from: http://content.healthaffairs.org/cgi/doi/10.1377/hlthaff.12.4.7<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">10. &nbsp;&nbsp;&nbsp;&nbsp; Perilla JL. Domestic Violence as a Human Rights Issue: The Case of Immigrant Latinos. Hisp J Behav Sci [Internet]. 1999 May 1 [cited 2014 Nov 23];21(2):107–33. Available from: http://hjb.sagepub.com/cgi/doi/10.1177/0739986399212001<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">11. &nbsp;&nbsp;&nbsp;&nbsp; Peskin MF, Markham CM, Shegog R, Baumler ER, Addy RC, Tortolero SR. Effects of the It’s Your Game . . . Keep It Real program on dating violence in ethnic-minority middle school youths: a group randomized trial. Am J Public Health [Internet]. 2014 Aug [cited 2014 Nov 19];104(8):1471–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24922162<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">12. &nbsp;&nbsp;&nbsp;&nbsp; States U. Intimate Partner Violence</span><span style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;"> </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">: Consequences Cost to Society. J Fam Violence. 2011;26(8):565–74. <o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">13. &nbsp;&nbsp;&nbsp;&nbsp; States U. Injury Prevention &amp; Control</span><span style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;"> </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">: Division of Violence Prevention The Social-Ecological Model</span><span style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;"> </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">: A Framework for Prevention. 2002; <o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">14. &nbsp;&nbsp;&nbsp;&nbsp; Steinberg L. Cognitive and affective development in adolescence. Trends Cogn Sci [Internet]. 2005 Feb [cited 2014 Jul 10];9(2):69–74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15668099<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">15. &nbsp;&nbsp;&nbsp;&nbsp; Stover CS, Meadows AL, Kaufman J. Interventions for intimate partner violence: Review and implications for evidence-based practice. Prof Psychol Res Pract [Internet]. 2009 [cited 2014 Nov 11];40(3):223–33. Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/a0012718<o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">16. &nbsp;&nbsp;&nbsp;&nbsp; Wekerle C, Wolfe DA. Dating Violence In Mid-Adolescence: Theory Significance, And Emerging Prevention Initiatives. 1999;19(4):435–56. <o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">17. &nbsp;&nbsp;&nbsp;&nbsp; Whitaker DJ, Morrison S, Lindquist C, Hawkins SR, O’Neil J a., Nesius AM, et al. A critical review of interventions for the primary prevention of perpetration of partner violence. Aggress Violent Behav [Internet]. 2006 Mar [cited 2014 Oct 30];11(2):151–66. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1359178905000546 <o:p></o:p></span></div><div style="line-height: 200%; margin-left: 32.0pt; text-indent: -32.0pt;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-no-proof: yes;">18.&nbsp;&nbsp;&nbsp;&nbsp; Qu MC,&nbsp;Halfron&nbsp;N.&nbsp;&nbsp;Racial and ethnic disparities in birth outcomes: a life-course perspective.&nbsp;&nbsp;Maternal and Child Health J 2003; 7(1):13-30.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"> </div><div class="MsoNormal" style="line-height: 200%;"><br /></div>Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-41651532552606070552014-12-18T13:51:00.000-08:002014-12-18T13:52:46.881-08:00Getting Wrapped Up In The Moment With Condom Use: A Critique of the DC Rubber Revolution Campaign –Ashley Mayo <div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Introduction: DC Takes on HIV</span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Our nation’s capital, Washington DC, is known for its political savviness, cultural diversity, and business oriented-nature; however, when it comes to public health, this city continues to struggle in the fight against HIV/AIDS. DC is one of the cities hardest hit by HIV in the United States, with an epidemic on par with some developing nations<sup>8</sup>. In addition, it has the highest AIDS diagnosis rate of any state in the U.S.<sup>8</sup>. This shows a dire need to not only further explore factors associated with HIV/AIDS prevalence, but also, find proactive methods to better education and equip residents. In 2008, the Department of Health (DOH) created <i>DC Takes on HIV</i>, a multi-pronged prevention program with three distinct parts:<sup><o:p></o:p></sup></span></div><div class="MsoListParagraphCxSpFirst" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: 1.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal; line-height: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Ask for the Test </span></i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(HIV testing campaign)<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: 1.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal; line-height: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">I Got This</span></i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"> (HIV Treatment campaign)<o:p></o:p></span></div><div class="MsoListParagraphCxSpMiddle" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: 1.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;"><!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal; line-height: normal;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><!--[endif]--><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Know Where You Stand </span></i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 150%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">(Intimate partner communication campaign)<sup>5</sup><o:p></o:p></span></div><div class="MsoListParagraphCxSpLast" style="line-height: 150%; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: 1.0in; margin-right: 0in; margin-top: 0in; mso-add-space: auto;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">The <i>DC Takes on HIV</i> campaign was intended to create awareness of HIV testing and treatment; however, the program struggled to contain DC’s soaring HIV prevalence rate. In 2010, the DOH conducted a study to evaluate socio-economic factors contributing to HIV rates and found that the campaign was missing a major component—condoms<sup>4</sup>. It was found that between 40% and 70% of all DC adults and adolescents reported not regularly using condoms<sup>4</sup>. As a result, The Rubber Revolution campaign was created to raise awareness about the city’s free condom distribution program, encourage condom use, and dispel misconceptions regarding condoms<sup>4</sup>. &nbsp;The program offers four ways for residents to obtain condoms, including direct mailing of up to 10 free condoms, telephone hotline to determine nearby condom distribution location, and text messaging services to find free condom locations by zip code<sup>4,7</sup>. The Rubber Revolution promotional campaign includes a public website (</span><a href="http://www.rubberrevolutiondc.com/"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">www.rubberrevolutiondc.com</span></a><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">), ads on radio, newspapers, and transit (which can be found at the end of this paper in “Images” section), and social media pages, on Facebook, Twitter, and Youtube<sup>4,15</sup>. By increasing access and awareness of free condoms, the DOH hoped to see an increase in condom use and ultimately decrease in the spread of HIV. However, after four years of health messaging, it is unclear of the actual success of the Rubber Revolution. A recent evaluation of the <i>DC Takes on HIV</i> program found that 28% of residents report frequent use of condoms during sexual activity<sup>5</sup>. Yet, the same report also showed that only 14% of residents could recall or was aware of the Rubber Revolution condom distribution program in the district<sup>5</sup>. Although the DOH attributes increased condom use to the campaign, this discrepancy shows the need to further improve campaign efforts. &nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">The Theoretical Approach of the Rubber Revolution<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Although on the surface this program is a health campaign for condom use, the Rubber Revolution is a social movement for safer sex in DC. Sociologist Mancur Olsen’s “resource mobilization theory” explains the importance of societal structure factors within mobilizing a population towards a cause<sup>10</sup>. The theory suggests that both persuasion and access to a limited yet necessary resources are essential for increasing participation of any social movement<sup>10</sup>. The Rubber Revolution models this theory in its attempt to increase access to condoms and cleverly persuade residents to increase condom use through advertisement. However, it unequally focuses its attention on increasing access without effectively stressing the importance of joining the safer sex movement. &nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Therefore, the major shortcoming within the Rubber Revolution is its inability to captivate and motivate participation and mobilization<sup>10</sup>. When the intervention was first created, a study found that 40% of heterosexual couples were not using condoms and a whopping 70% of intravenous drug users were not using them in DC<sup>12</sup>. After four years of the campaign, it was found that 71% of all DC residents are aware of condom distribution locations, but only 28% reported using them more frequently<sup>5</sup>. While this is a small victory for the Rubber Revolution, there is still a barrier blocking individuals from using condoms—the desire and understanding of why this is important. Following the resource mobilization theory, the Rubber Revolution must work to complement increased access efforts with a campaign strategy that evokes community involvement<sup>10</sup>.&nbsp; If the campaign is unable to engage the community, then it will not have the participation it needs to successfully reach DC residents. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Although it is not formally stated how one can join the “revolution”, it appears that it is defined by increased condom use, social media engagement on Facebook and Twitter, or a commitment to practice safer sex. According to the theory, participation within a movement results from "weighing" costs against benefits, which the intervention is not successfully achieving<sup>10</sup>. If residents are not seeing the major benefits of joining the revolution, then they are less likely to do so. Although the Rubber Revolution could greatly benefit the community, there is a need to improve the major methods of persuasion by: clarifying the intended audience, providing educational opportunities for residents, and increasing the campaigns social presence in DC.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"><br /></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Critique 1: The Rubber Revolution Lacks Focus in its Intended Audience<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">The Rubber Revolution diminishes its efforts by not having a clear intended audience is for the campaign. Since this is a multi-pronged intervention, it appears the DOH chose to dilute messaging about condom use to all residents. According to framing theory, a one-size fits-all approach hinders a campaign’s potential benefits of changing perceived attitudes toward a behavior<sup>3</sup>. &nbsp;Framing theory refers to the process by which people develop a particular conceptualization of an issue or reorient their thinking about an issue<sup>3</sup>. By broadly framing this condom intervention, the Rubber Revolution could appear not relatable to many residents who already have a low perceived risk of HIV and other STDs. Therefore, in some cases, it is better to have an identified intended audience to better relay health messaging. Nevertheless, by exploring advertisement marketing and media communication, it appears that the Rubber Revolution is framed to engage males and teens. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">First, framing theory suggests that a frame is always related to a specific issue or event in media communications<sup>3</sup>. For the Rubber Revolution, it appears that males are a possible intended audience, as a result of startling statistics regarding this population. In 2007, heterosexual contact and men who have sex with men (MSM) contact were the two leading sexual transmission modes of new HIV cases<sup>5</sup>. More recently it was also found that 72% of people living with HIV and new HIV diagnoses in DC are males<sup>8</sup>. These two findings show a clear need to engage males through campaign efforts, which the Rubber Revolution successful accomplishes. Every promotional piece depicts a male figure and refer to condom misconception involving males. For example, one campaign advertisement depicts an African American male preparing to play basketball but instead of a basketball hoop, there is a huge condom<sup>15</sup>. The ads simply says, “Big Enuf 4 U”, which the DOH identified as a common reason why DC residents refused to use condoms<sup>4,15</sup>. This messaging to males could serve as evidence that this is the intended audience, but it is still unclear if that was the DOH intention. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Secondly, framing theory describes the production of frames as a constant interaction between the media and the public articles<sup>3</sup>. Since the Rubber Revolution lacked to provide a target audience, the media framed messages towards a population that they perceived was best—teens. Media outlets, including Fox News, has coined the Rubber Revolution as an “increased ability to protect teens from diseases and unwanted teen pregnancy”, which are above average in the city<sup>7</sup>. Media agenda setting theory (which is closely related to framing theory) suggest that media coverage leads to changes in importance to different considerations<sup>3</sup>. Although most of the research regarding HIV in DC is for adults, the media has found teens as the biggest benefactor of the campaign, due to common perceptions of overly sexual teens. In support of this frame, the literature does suggest that the HIV epidemic is beginning to impact DC youth and could be a great starting place to lessen the epidemic<sup>8</sup>. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Another major defense for the teen population&nbsp; is the use of social media as a major form of communication within this campaign. The Rubber Revolution features a website equipped with blogs, fun quizzes, and information, a text messaging service and social media profiles on Twitter, YouTube, and Facebook<sup>4</sup>. Although anyone can access these communication channels, it appears that the campaign seeks to engage the teen population who use these social outlets more frequently<sup>4</sup>. Therefore, it is possible that the campaign is indirectly choosing teens as the intended audience, yet neglects to frame messages to them. For the sake of clarity and consistency, I will assume that the Rubber Revolution targets teens, as opposed to males in general.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"><br /></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Critique 2: The Rubber Revolution Fails To Include Educational Opportunities for Residents <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Since the Rubber Revolution focuses heavily on condom accessibility, it appears that the campaign assumes that DC residents are educated on proper condom use. Currently, condom distribution occurs in over 100 locations around the city, but residents must rely on the Rubber Revolution website for a three step condom instructional picture<sup>6</sup>. In addition, the program also offers a webpage for discrete condom package mailings and a toll-free number to order condoms, but again there lacks educational information in packaging<sup>6</sup>. This is problematic because it places greater responsibility on the individual to access information about proper use, as opposed to having it readily available. &nbsp;It is possible that the Rubber Revolution is overlooking potential educational gaps, due to DC incorporation of comprehensive sex programs in schools or prior knowledge. A recent citywide survey found that that 85% of parents agreed DC schools are responsible for teaching their children age-appropriate HIV prevention and sex education, yet 90% believe that the school’s role is to provide “biological and scientific” sex education information<sup>19</sup>. As a result, teens are receiving mixed or incomplete messages regarding sex from school, family, the media, and peers. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">It is arguable that the Rubber Revolution’s emphasis on condom use also sends a confused message to teens regarding sex. As a condom focused intervention, it is essential to promote the benefits of condoms without sending a message that condoms are the ultimate protection from STDs and unwanted pregnancy. When the Rubber Revolution was first created, it was accused of encouraging sexual activity among teens by distinguishing condom use as social normative behavior. As a response, Michael Kharfen, the Health Department's community outreach bureau chief, attempted to clarify the message by asserting the campaign doesn’t “recruit people to have sex” but promotes that “</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;;">condoms are the only device that protects you from these diseases and unwanted pregnancy"<sup>7</sup>. By framing condom use as an ultimate form of protection, teens could perceive their risk of unwanted circumstance unlikely with condom use. Nevertheless, this protection frame doesn’t take into account the importance of proper condom use as a way to ensure optimal protection. This shows a need to not only encouraging teens to use condoms, but also ensuring that they are using it correctly. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;;">Another consequence to having a solely condom-focused program is the impact of psychological self-filling prophesies among teens. &nbsp;Psychologist Robert Merton coined the phrase self-fulfilling prophecy to describe “situations that evoke a new behavior, in response to an originally false conception”<sup>1</sup>. Within the Rubber Revolution, condoms are distributed as a means to encourage teens to participate in safer sex practices; however, by vigorously promoting condom use, the program could motivate teens that were not sexual active to begin having sex, in order to fulfill the “prophesy” of the program<sup>1</sup>. Although there is not sufficient evidence to prove that the program is encouraging adolescents to become sexually active, the protection core value used to describe condoms could be a strong motivator for teens. If teens perceive their risks of unwanted pregnancy and STDs as minimal with condom use, then engaging in sexual activity is perceived as simply satisfying social norms. It may be important for this intervention to find ways to counteract self-fulfilling prophesy, while also encouraging condom use among sexually active teens. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;;"><br /></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 1.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;;">3</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 2.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Critique 3: The Rubber Revolution Has a Limited Social Presence</span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"> <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">The Rubber Revolution is described as a social campaign for DC residents, yet residents are seemingly unaware of the program. In a city-wide sample, only 14% of DC residents could recall seeing campaign related materials find the majority of those individuals saw transit ads and TV commercial<sup>5</sup>. In response, DC residents are less likely to use these services because they don’t of its existence. A recent evaluation of the program found that 5% of residents reported using social media sites and websites, 6% for telephone services, and 3% for text messaging services, regarding condom distribution<sup>5</sup>. This shows that the outreach’s limited scope and messaging is not reaching the community as planned. The DOH has identified this low social media presence as a problem, but there doesn’t appear to be any major changes suggested to improve this effort<sup>5</sup>. According to the theory of preventative innovation, new ideas that are perceived by individuals as having greater relative advantage, compatibility, and less complexity will be adopted more rapidly than other innovations<sup>14</sup>. The Rubber Revolution is likely experiencing limited new adopters in the innovations model due to limited perception of program benefits. Therefore, the campaign must consider a strategy to increase the number of new adopters by activating peer networks through the use of program “champions”<sup>14</sup>. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">According to the theory of preventative innovations, the Rubber Revolution is missing the opportunity to engage DC residents due to lacking social processes. By encouraging people to talk about the condom use, it will give increased condom use a new meaning within the social setting and potentially encourage others to adopt<sup>14</sup>. The theory describes the use of “champions” as the best way to increase peer networks. Program “champions” are individuals who devote their personal influence to encourage adoption of an innovation<sup>14</sup>. Currently, the Rubber Revolution media partner is radio/TV personality Big Tigger who was one of the campaign’s first ambassador to encourage condom use and safe sex<sup>4</sup>. While Big Tigger is beloved in the DC community, the use of one champion for the Rubber Revolution doesn’t increase peer networks in the same effect as many champions would. &nbsp;&nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Also, the theory of preventative innovations identifies the importance of changing the perceived attributes towards the desired activity, as a means to increase new adopters<sup>14</sup>. Kharfen promotes the Rubber Revolution as a way to remove the stigma regarding condom use by “changing the conversation”<sup>7</sup>. The campaign has made a commendable effort to inform misconception involving condom use, such as “Life Feels Better with a Condom”, “Big Enuf 4 U”, and “A Condom Fits Any Head”<sup>4</sup>. Neverhteless, the campaign neither relays the relative advantage of this preventive innovation of condom use nor provides clear information on where to get condoms on advertisement and how to join the revolution<sup>14</sup>. This lack of vital information could impact ones intention to adopt the Rubber Revolution promotion of condom use as a new innovation because it appears inaccessible and too complex.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">The campaign also needs to become more aware of the “new conversations” that it seeks to start regarding condom use. The campaign received backlash for its “What Condom are You?” pop quiz, as a way to “engage people in a different way"<sup>7</sup>.&nbsp; For example, if you prefer cheeseburgers to a salad, club soda to champagne, work a 9-to-5 day and enjoy network comedies and reggae, you're a standard latex condom<sup>6,7</sup>. Although the test seems like a fun and harmless quiz, it is unclear of what message it seeks to send to residents.<o:p></o:p></span></div><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-indent: 0.5in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Proposed Improvements for the Rubber Revolution</span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;"> <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Although this intervention poses many theoretical dilemmas, in terms of influencing behaviors, it is still a unique and progressive in its approach to decrease HIV/AIDS prevalence. For a city, like DC, a promotional campaign is the best option because of the amount of people that commute, travel, and are physically inside the city daily. Nevertheless, the program must work toward really encouraging individuals to join a revolution of people who understand the benefits of condom use. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Use the Rubber Revolution to Target Teens and Condom Use<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Based on services provided and media framing of the campaign, the Rubber Revolution should direct its focus on DC teens<b>. </b>Although the impact of HIV varies by age in DC, there are some indications that the epidemic is starting to take a greater toll on younger residents<sup>8</sup>. If the campaign creates additional ads that focus on this population, it could increase future condom use and decrease rates of HIV/AIDS in the city. By applying social norm theory, it could reframe condom use as a popular behavior for teens, which would serve as a normative influence for other teens to engage in the practice<sup>11</sup>. But in order to do this, the Rubber Revolution must design settings and messages that are relatable and familiar for teens. For example, the Rubber Revolution commercial depicts a group of adults enjoying a night out at a lounge, with each individual committing to safer sex by using a condom<sup>18</sup>. The commercial does provide a diverse casting of middle-age heterosexual and homosexual couples of various ethnicities to represent DC residents. Yet, this setting is not relatable to the teen population because it depicts scenarios that teens are not allowed to do. This could lead teens to underestimating their perceived risk, which defeats the purpose of the campaign. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Therefore, there is a need to include teen appropriate advertisement that uses values that are important to this population. For example, there could be a commercial where a group of teens are going to a homecoming dance or prom and commit to safer sex practices by using a condom. By simply changing the actors and setting, the commercial now evokes values that are important to teens. In addition, the Rubber Revolution should also incorporate non-male dominant promotional pieces to promote condom use as a gender neutral activity. Condom use is often perceived as a male initiated activity, but by reframing this perception, the campaign includes women in the conversation about safer sex. For example, there can be an ad that depicts a women initiating condom use with the tagline, “I am always prepared”. This ad evokes the core values of independence and equality for women who want to take control of their sex lives. As a result, the revolution is presented as a less male-dominated effort and encourages female participation in the movement.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Within social norm theory, a change in behavior can only occur when an injunctive norm (beliefs about what ought to be done) becomes a descriptive norm (beliefs about what is actually done in a social group)<sup>11</sup><b>. </b>Currently, condom use is seen as an injunctive norm in DC, but it could become a descriptive norm, if the Rubber Revolution improves its methods of outreach to teens and women. By actively engaging this population using commercials, promotional ads, social media sets, and YouTube, there is no telling the amount of support and success that can be achieved for the revolution. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Incorporating an Educational Component to Rubber Revolution <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Based on the Sexual Health Model, the theoretical framework for improving individuals overall sexual well-being would be the inclusion of additional information regarding sex and condom use<sup>13</sup>. Through DOH partnerships with local organizations, condom distribution was found most popular in local health clinics, hair salons and barbershops, restaurants, and community-based organization<sup>5</sup>. Yet, there doesn’t appear to be any major forms of educational pieces provided alongside condom distribution. By simply providing, educational brochure or miniature condom instructions at each location could increase efficacy of condom use.&nbsp; In addition, the DOH should consider distributing safer sex kits, as opposed to single condoms. Each safer sex kit could be equipped with two condoms (in the case that one breaks during use), condom instructions, and water-based lubricate. Incorporating safer sex kits would allow for all residents to have easily accessible information regarding proper condo, as opposed to leading residents to a website to obtain information. The DOH could also create an exclusive Rubber Revolution condom card collection that can be placed alongside safer sex packets. (Note: It should not be included inside of safer sex kits to prevent puncturing condom). The condom cards would include condom tips, such as check for expiration before use, ensure that you leave room at the tip, and avoid wearing two condoms at one time. The goal of this collection of cards is to creatively address common misperceptions of condom uses and reduce stigma, which have been identified as major barriers in DC condom use<sup>4</sup>. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Although it is arguable that DC teens are fully knowledgeable about sexual health, the Sexual Health model encourages a comprehensive approach to sex. In 2012, DC released the results of its first ever standardized test on health and sexual education, which high school scored on average 75% in sexual health questions<sup>2</sup>. Although these are great scores, the Sexual Health Model warns against interventions overly assuming that individuals are sex literate and more likely to make healthy decision regarding sex, including condom use<sup>13</sup>. Therefore, it is important that the campaign sends accurate and consistent messages regarding condom use and protection to teens. By incorporating peer educator models within the Rubber Revolution, the campaign will not only activate social observation and role modeling, but also reinforce accurate information regarding sexual health<sup>20</sup>. Peer health educators would be volunteer teens from around the city who are given extensive training regarding comprehensive sexual health. Once trained, they will serve as teen representations of the Rubber revolution, encourage peers to practice safer sex, and establish a brand for the campaign.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">In order to counteract the potential effects of self-fulfilling prophesy, there could be the inclusion of promotional advertisements framed to include abstinence as an even better preventative measure. For example, an ad could depict a couple hugging with the tagline, “Waiting never felt so good, but I am always prepared”. This ad sends the messages that it is okay to abstain from sexual behavior, but also good to protect yourself, if the choice is made to have sex. By including abstinence, the campaign not removes the stigma regarding abstinence and creates awareness to sexually active individuals the importance of condom use. This would also satisfy the Sexual Health Models that encourage a comprehensive and inclusive approach to sex education. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Increase the Rubber Revolution Presence Using Social Media<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">There is a need to increase the Rubber Revolution’s social presence in DC by improving social networks. Currently, the Rubber Revolution has 850 Twitter followers, 185 likes on Facebook, and 4 You Tube videos (with two of the videos offering instructional videos for female condom use, which is not offered within this program)<sup>16-18</sup>.&nbsp; Considering this program has existed for four years, this shows the minimal social presence of the campaign the Rubber Revolution. In order to quickly increase followership, the DOH could implement membership strategies on social media profiles. First, there could be a major raffle or giveaway to encourage new followers on social on Twitter and Facebook. The promotion could raffle free VIP tickets to a local basketball or baseball for the first 1000 followers on both Facebook and Instagram. Secondly, thre could be a YouTube contest for DC teens to post videos of why they believe in safer sex. Residents with the best videos will be combined and premiered on the website and local television channels. By actively engaging teens, the Rubber Revolution could increase social presence on multiple social mediums and have an array of promotional videos to use for future campaign strategies. Immediately following promotional contest, it is crucial for the campaign to compose eye-catching, interesting facts regarding condom use and sexual health to post on Twitter and Facebook to maintain followership. In addition to each post, the campaign should increase social branding, through the use of hashtags (#). For example, each post she conclude with #RubberRevolutionDC and #FreeCondomsDC, in order to increase social searchability and awareness of the program. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">Next, there is a need for more media role models and champions for the campaign. The Natural helper model suggests that an individual, who is respected, empathetic, trusted, who listen well, sufficiently in control of their own life circumstances, and responsive to the needs of others, could increase social networks<sup>9</sup>. While this may be difficult to determine, the Rubber Revolution could instead identify individuals at local recreational centers and schools to serve as natural helpers, in the efforts to increase condom use. For example, they could target local basketball teams and cheerleaders as program champion because of the level of popularity within the school. If popular groups within school settings perceive condom use as important, then others are more likely to adopt this new practice. According to the theory of preventative innovation, this should result in an increase in social networks for the campaign and most importantly, increase in condom use.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-fareast-font-family: &quot;Times New Roman&quot;;">In order to “change the conversation” regarding condom use, the DOH should include advertisements that cleverly display the perceived benefits of condom use. For example, the Rubber Revolution addresses a common misconception that condoms are too small for some individuals by using the advertisement taglines, “Big Enuf 4 U” and “A Condom Fits Any Head”<sup>19</sup>. While these are eye catching, the DOH could must find a way to show the perceived benefits of condom use without relying too heavily on statistics. It is clear that condom lowers one’s chances of STI transmission and unwanted pregnancy so the campaign must find a way to cleverly state these facts. By using a frame of protection, the DOH could use taglines, such as “Actively protected with condoms”, “Condom Status: Protected and Free” or “The Safest Hat for Any Head” would better express perceived benefits of use. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%;">Conclusion<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; margin-bottom: .0001pt; margin-bottom: 0in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 200%;">In closing, the DOH and Rubber Revolution presents a compelling campaign to encourage resident to “get those rubbers out of your wallet, remove them from your purses and pull them out from under the beds of every ward in the city”<sup>4</sup>. Nevertheless, it gets too wrapped up in the moment because there remains a dire need for improved program direction, greater educational opportunities, and increased social presence for the Rubber Revolution in DC. <o:p></o:p></span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><b>REFERENCES</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">1.<span class="Apple-tab-span" style="white-space: pre;"> </span>Bearman, Peter and Hedström, Peter. Self-Fulfilling Prophecies. Oxford University Press. 2009.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://users.ox.ac.uk/~sfos0060/prophecies.shtml &nbsp;(accessed 8 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Brown, Emma. D.C. releases results of nation’s first-ever standardized test on health and sex ed. The Washington Post. December 12, 2012.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://www.washingtonpost.com/blogs/dc-schools-insider/post/dc-releases-results-of-nations-first-ever-standardized-test-on-health-and-sex-ed/2012/12/12/c52da276-4494-11e2-8061-253bccfc7532_blog.html (accessed 4 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Chong, Dennis and Druckman, James. Framing Theory. Annual Review of Political Science 2007; 10:103–26</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">4.<span class="Apple-tab-span" style="white-space: pre;"> </span>DC Department of Health. The District Starts a “Rubber Revolution” to Increase Condom Use. The Department of Health. November 18, 2010.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://DOH.dc.gov/release/district-starts-%E2%80%9Crubber-revolution%E2%80%9D-increase-condom-use (accessed 5 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">5.<span class="Apple-tab-span" style="white-space: pre;"> </span>DC Department of Health and HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA). DC Takes on HIV: Public Awareness, Resident Engagement and a Call to Action. Octane Public Relations and Advertising. November 2014.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://DOH.dc.gov/sites/default/files/dc/sites/DOH/publication/attachments/DC_Takes_on_HIV_Public_Awareness_Resident_Engagement_and_a_Call_to_Action.pdf (accessed 5 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">6.<span class="Apple-tab-span" style="white-space: pre;"> </span>D.C.’s “Rubber Revolution” Matches Condoms to Personalities. Judicial Watch. November 18, 2010.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://www.judicialwatch.org/blog/2010/11/rubber-revolution-matches-condoms-personalities/</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">7.<span class="Apple-tab-span" style="white-space: pre;"> </span>Fox News. D.C. Condom Program Sends Wrong Message, Abstinence Group Says. Fox News- Politics. November 18, 2010.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://www.foxnews.com/politics/2010/11/18/dc-condom-program-sends-wrong-message-abstinence-group-says/ (access 25 November 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">8.<span class="Apple-tab-span" style="white-space: pre;"> </span>Israel, Barbara A. Social Networks and Social Support: Implications for Natural Helper and Community Level Interventions. SOPHE Health Education Quarterly 1985; 12(1): 65-80.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">9.<span class="Apple-tab-span" style="white-space: pre;"> </span>Klandermans, Bert. Mobilization and Participation: Social-Psychological Expansions of Resource Mobilization. American Sociological Review 1984; 49(5): 583-600.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">10.<span class="Apple-tab-span" style="white-space: pre;"> </span>Knight Lapinski, Maria and Rimal, Rajiv N. An Explication of Social Norms. International Communication Association 2005; 15(2): 127–147.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">11.<span class="Apple-tab-span" style="white-space: pre;"> </span>Montague, Candice &nbsp;Y.A. The Rubber Revolution begins in DC. The Examiner Newspaper. October 28, 2010</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://www.examiner.com/article/the-rubber-revolution-begins-dc</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">12.<span class="Apple-tab-span" style="white-space: pre;"> </span>Robinson, Beatrice; Bockting, Walter. Rosser, Simon. Miner, Michael; and Coleman Eli. The Sexual Health Model: application of a sexological approach to HIV prevention 2002; 17(1): 43-57.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">13.<span class="Apple-tab-span" style="white-space: pre;"> </span>Rogers, Everett. Diffusion of preventative innovations. Addictive Behavior 2002; 27 (2002): 989-993.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">14.<span class="Apple-tab-span" style="white-space: pre;"> </span>Rubber Revolution DC. Octane Public Relation Advertising. 2014.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://octanepra.com/rubber-revolution-dc/#!<span class="Apple-tab-span" style="white-space: pre;"> </span>(accessed 4 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">15.<span class="Apple-tab-span" style="white-space: pre;"> </span>Rubber Revolution DC. Facebook, 2014.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">https://www.facebook.com/RubberRevolutionDC &nbsp;(accessed 9 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">16.<span class="Apple-tab-span" style="white-space: pre;"> </span>Rubber Revolution DC. Twitter.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">https://twitter.com/freecondomsdc (accessed 9 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">17.<span class="Apple-tab-span" style="white-space: pre;"> </span>Rubber Revolution DC. You Tube.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">https://www.youtube.com/user/RubberRevolutionDC (accessed 9 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">18.<span class="Apple-tab-span" style="white-space: pre;"> </span>Sexuality Information and Education Council of the United States. Poll Shows DC Parents Strongly Support Comprehensive Sex Education in Schools. 2008.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&amp;featureid=1497&amp;pageid=483&amp;parentid=478<span class="Apple-tab-span" style="white-space: pre;"> </span>(access 5 December 2014)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">19.<span class="Apple-tab-span" style="white-space: pre;"> </span>The Henry J. Kaiser Family Foundation. The HIV/AIDS Epidemic in Washington, D.C. Fact sheet. &nbsp;July 2012.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 18.3999996185303px;">20.<span class="Apple-tab-span" style="white-space: pre;"> </span>Turner, G. and Shepherd, J. A method in search of a theory: peer education and health promotion. Health Education Research Theory and Practice 1999; 14 (2): 235–247.</span></span></div><div><br /></div><div class="MsoNormal"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; font-size: 12.0pt; line-height: 115%;">&nbsp;</span><span style="font-family: Georgia, serif; font-size: 12pt; line-height: 115%;">&nbsp;</span></div>Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-59930221991199246962014-12-18T13:37:00.001-08:002014-12-18T13:37:48.660-08:00Public Health Intervention Critique: A Traditional Approach to Health Education in Schools – Sarah Benes<b>Introduction: What is Traditional Health Education?</b><br /><br />Health education is an integral component of an effective educational program. It has the ability to “reduce the prevalence of health risk behaviors among students and have a positive influence on students’ academic performance” (1). Moreover, many studies and articles support the idea that good health can help students perform better in school because they are more likely to attend school, to be able to concentrate, and to perform well - healthy children are more ready and able to learn (2-6). The Centers for Disease Control and Prevention (CDC) also suggest that academic success can be an “indicator for the overall well-being of youth and a primary predictor and determinant of adult health outcomes” (2). Health and academic outcomes are linked in a way that improving one is likely to positively influence the other. Health education has the potential to be an effective public health intervention which can improve the current health behaviors of students, future health outcomes as well as positively contribute to learning.<br /><br />Despite the potential for health education, data from CDC from both the School Health Profiles and the Youth Risk Behavior Surveillance Survey (YRBSS), suggest that there are many students not receiving health education and that the current approach to health education may not be effective in decreasing risky behaviors. The 2012 School Health Profiles reveal that the percentage of states that require health education ranges from 51.3% offering a health education course in 6th grade, to 63.9% in 8th grade, to 57.2% in 9th grade and down to 47.1% in 10th grade (7). There are many states that still do not have health education requirements for grades at the secondary level which means that the reach of school based health education is limited. As a public health approach, it is clear that there is untapped potential for health education to impact students at a critical time when they are engaging in behaviors and forming behavior patterns that are likely to continue into adulthood.<br /><br />While health education alone cannot directly impact the multiple influences on adolescent health behaviors (such as policies, environment, media, family and peers), it can be one aspect of an effective public health approach (8-10). Youth are engaging in a range of risky health behaviors many of which contribute to leading causes of death in the United States. Select data from the 2013 survey includes: 35% of high school students “currently drank alcohol”, 21% had 5 or more drinks in a row within the last 30 days, 23% currently use marijuana, 47% have ever had sexual intercourse, 34% are currently sexually active and only 59% used a condom during their last sexual intercourse (11). While this is a limited glance into the range of risky behaviors, this data supports the need for interventions which help students develop the knowledge and skills they need to choose health-enhancing behaviors and avoid risky behaviors. One way to do this is through effective health education in schools; however, a traditional approach to health education is not likely to help achieve these outcomes and yet this appears to be the current trend in schools in the US.<br /><br />According to the United Nations Educational, Scientific and Cultural Organization (UNESCO), traditional health education involves “learning about the human body, food nutrition, the importance of work and exercise and the problems of smoking, drugs and alcohol” (12). UNESCO further breaks down traditional health education into the following characteristics (12): Focus on disease;&nbsp;Moralistic tone;<span class="Apple-tab-span" style="white-space: pre;"> </span>&nbsp;Focus on individual behavior;&nbsp;Didactic teaching methods;&nbsp;Emphasis on “doing the right thing”;<br />Health experts as guest lecturers;&nbsp;Focus on health education (as opposed to a healthy school approach);&nbsp;A biomedical view of health;&nbsp;Teacher to model “right” behavior (as opposed to enquiry methods);<span class="Apple-tab-span" style="white-space: pre;"> </span>Students adopt prescribed attitudes and values.<br /><br />Traditional health education has also been characterized by being “like any other lesson,” by teaching issues that are not always relevant for the students, and by focusing on future outcomes rather than present outcomes which is not as effective with adolescents (13).<br /><br />While it can be challenging to collect data as to approaches actually implemented in classrooms (reported versus actual), data that is available supports that health education reflects a traditional approach. The median percentage of secondary schools that “have tried to increase student knowledge on health-related topics” are: 75.5% for suicide prevention, 81.8% pregnancy prevention, 88.7% STD prevention, 93.1% violence prevention, 93.5% tobacco-use prevention, 96.2% nutrition and dietary behavior and 98.5% for physical activity and fitness (7). In addition, the median for percentage of secondary schools with a health education curriculum that addresses all eight skills of the National Health Education standards (which is one way to determine the health education approach) is only 61.5%. It is important to note the language of the survey results/questions. In the “health topics” question it specifically asks if schools have tried to increase student knowledge whereas the skills question is much more general relating to having a health education curriculum which “addresses” skills. The phrasing “address skills” is more vague than “increasing student knowledge” and leaves room for interpretation about the extent to which the skills are “addressed” and how much emphasis is actually placed on the skills. For example, a more revealing question could be the extent to which the schools have “tried to develop the following skills in students” or the extent to which schools have “tried to increase students’ ability to demonstrate the following skills.” These questions would be more aligned with the “topic” question and get a better sense of what might actually be happening in classrooms. Nonetheless, the larger percentages of schools increasing student knowledge around health topics and the relatively low percentage of schools teaching skills suggests that there is still an emphasis on more traditional methods in health education.<br /><br />Health education has the potential to be an effective strategy for both improving students’ academic and health outcomes. However, in its current state, health education is not in a position to be a meaningful public health intervention. The three main critiques of the current approach are: 1) an emphasis on knowledge, 2) an emphasis on didactic methods and 3) the current framing of health education. However, there is a potential solution that is support by social science theory and research and which could be the approach that could help bring health education to the forefront as an effective intervention to address the health of today’s youth: a skills-based approach to health education.<br /><br /><b>Critique 1: Emphasis on Knowledge</b><br /><b><br /></b>There is limited evidence to support that knowledge of health topics will lead to behavior change (14-16). There needs to be more to health education than teaching “about” health topics (UNESCO). Health education should leverage the current research and theory about health behaviors which emphasizes an ecological approach to promoting health in which individual factors are only one piece of a larger puzzle rather than focusing on knowledge acquisition.<br /><br />To rely on increasing knowledge as the main intervention in health education ignores many of the more potent influences on behaviors such as peer influence, media and &nbsp;norms (both real and perceived). Even health behavior theories that focus on the individual still include more than knowledge alone. For example, the Health Behavior Model includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. While knowledge might impact perceived susceptibility, benefits and barriers it will not address cues to action or self-efficacy, both critical components of the model. In another common theory, the Transtheoretical Model, knowledge might be used to help someone move through a stage or between stages it would be most likely to have an impact on the earlier stages of precontemplation and contemplation. Clearly, knowledge is not the most important factor even within individual health behavior theories.<br /><br />Perhaps even more compelling is the fact that many have suggested that health behaviors are strongly influenced by social influences such as peers and the media. Thaler and Sunstein suggest that in order to “nudge” people into action three social influences should be addressed: information, peer pressure and priming (15). They argue that people are motivated to conform to social norms and to others behaviors whether real or perceived as well as the fact that people can be “primed” by providing them with cues and a channel to facilitate an action. The only knowledge involved here is in the form of “information” of social norms or of actions of others. Another example comes from Florida’s “truth” campaign in which they found that students did know the dangers of tobacco – “knowledge was not the problem” (17). As a result, the campaign focused in part on setting a tone that would connect with youth and making “truth” a brand in order to connect with the youth’s identify formation (17). Again, knowledge did not play a role in the campaign, in fact, it was clear that youth knew the dangers and that some still chose to smoke for reasons such as rebellion and as a way of asserting ownership over their decisions (17).<br /><br />There is much evidence to support that knowledge is not a key determinant in behavior from health behavior theories to research from the field. Therefore, health education fails to be effective, in part, due to its reliance on knowledge as the main focus. Teaching students about health is not going to impact behavior. Health education needs to move away from a foundation of knowledge to a foundation that is aligned with current theory and research.<br /><br /><b>Critique 2: Emphasis on didactic methods</b><br /><b><br /></b>Similarly, a focus on didactic, teacher-directed methods is equally as ineffective. Talking “at” people, especially youth, is not going to engage them. Didactic teaching is also more aligned with the idea that people make rational decisions – if we tell people how bad a certain behavior is, logically they will not engage in the behavior or, more broadly, if we give people all the information about certain health topics, they will have what they need and logically, they will make the right decision. As with the focus on knowledge, this approach neglects to take into account the irrationality of people’s decision making.<br /><br />Teaching health education can be compared to “selling” health much like many public health campaigns aim to sell a healthy behavior (not smoking, wearing condoms, etc.). Successful campaigns do not rely on “telling” people about the behavior, rather they engage an emotional appeal and use marketing techniques. For example, Randolph and Viswanath created a list of criteria necessary for successful public health campaigns including: ensuring exposure of messaging, creative marketing and messaging, a supportive environment, theory-based and targeted to the audience (18). If this is translated into the classroom one might expect to see a teacher who uses these methods in their instruction. For example, teachers have one advantage in that they can control the exposure to the message in their classroom and may also be able to impact messaging in the school. The teacher can create a supportive environment in which students feel safe and in which there is some ownership. The teacher can use participatory methods which engage students in order to create messages that will resonate with students and they could target their curriculum and their teaching to meet the needs of their students. This cannot occur in a didactic classroom where the teacher is mainly “giving” information to students through teacher-directed messages. In many ways, this is in contrast to what is known about how to compel an audience to change behavior or to “buy into” an idea or concept.<br /><br />Didactic teaching also goes against the principles in the ecological approach to health education. In particular, didactic teaching is less likely to meaningfully address perceptions, skills, motivations and the social environment (19). While there are multiple ways to address these factors, participatory teaching methods are more effective than didactic. Participatory teaching techniques include the use of techniques for skill development, interactive teaching, and a social context for learning (6). This results in instruction that allows students to see change in the present, as opposed to teaching them knowledge that might help them in the future. Students are directly involved in their learning experiences and much of the instruction is focused on giving students the knowledge and skills they need now and in the future. These ideas are much different than those presented above regarding traditional health education which focuses on didactic learning and fact acquisition. When one engages students through a participatory approach, students can explore and discuss their perceptions. The teacher can also use principles of social influence to “nudge” students toward health-enhancing behaviors and attitudes. The teacher can create a social environment that is supportive (successful public health campaigns), that focuses on health enhancing norms and behaviors and which provides opportunities for students to positive influence one another. Finally, participatory methods provide opportunities for students to develop skills, another key determinant in an ecological approach to health behavior.<br /><br />Didactic methods are not aligned with practices in public health campaigns or an ecological approach to health behavior. While health education is not a traditional public health campaign, lessons learned from the public health field can be directly applied to health education in the classroom. Upon evaluation, a didactic approach is not aligned with current practice in the public health field. Lessons learned from the public health field should be applied, where appropriate, in the health education classroom which would include moving away from a didactic approach which is a second reason why health education is not currently an effective public health intervention.<br /><br /><b>Critique 3: Current Framing of Health Education</b><br /><b><br /></b>A third critique of health education is the weak framing of health education in schools. There are four main frames for school-based health education described here:<br />Frame: 1)&nbsp;Health Education Matters – Really! 2)&nbsp;Health and Academics 3)&nbsp;Health Education on the Periphery<span class="Apple-tab-span" style="white-space: pre;"> </span>&nbsp;4)&nbsp;Not the school’s job<br /><br />Core Position:<span class="Apple-tab-span" style="white-space: pre;"> </span>Health education, despite current opinion, does make a difference and belongs in schools.&nbsp;Health contributes to academic success (and alternately negative health behaviors negatively impacts academic success).&nbsp;Health education is not a core part of a quality education.<br />Parents/families, not teachers and schools, should be educating students about health.<br />The main issues with these frames are that three are defensive frames and one is a frame against health education in schools. It not surprising then that health education is not a requirement in more schools and why greater attention hasn’t been paid to health education as a viable public health approach.<br /><br />Health education is fighting an uphill battle to begin with and when the main messaging relies on a defensive stance it serves as a cycle where people’s ideas that health education doesn’t matter are essentially reinforced since the frames seem to acknowledge the same facts – that health education is on the periphery in schools, that health but not necessarily health education can support academics and that despite what people think, it does matter – really. With weak frames like these, it would follow that there isn’t strong support for health education and then that there would be a lack of attention paid to health education. Instead of these frames, health education should use a value frame and an offensive stance that health education belongs in schools and is an effective intervention. There is data that supports health education in schools that should be leveraged to create a frame which has a core position that health education is a core subject which can provide students with the knowledge and skills necessary to be healthy now and in the future. Finally, there is also data to support that parents do want health education in schools (20) and the frame could use a “right to education” core value to argue that students have the right to health education delivered by a qualified teacher who has been trained in health education. Relying on outside sources can lead to misconceptions, misinformation and a lack of development of skills and attitudes needed to be healthy. The current framing is a third problem with health education in its current form.<br /><br /><b>Proposed Intervention: A skills-based approach to health education</b><br /><b><br /></b>The first major aspect of skills-based health education is the content – the actual subject matter that is taught to students – which includes both health-related concepts and skills. The National Health Education Standards (NHES) were created by the Joint Committee on National Health Education Standards to provide a framework for “aligning curriculum, instruction, and assessment practices” in health education (21). &nbsp;The standards were recently revised from the original published in 1995 to reflect the need for “health-related knowledge, skills and healthy beliefs, and values and norms” in school curricula (22). The standards themselves also reflect this need as only one of the standards relates to health-related concepts, the other seven relate to the following skills: analyzing skills, accessing information, interpersonal communication, decision-making, goal-setting, practicing health-enhancing behaviors and advocacy (21).<br />Health educators using a skills-based approach should use these national standards as a foundation on which to build their curriculum. The health-related concepts to be included in the curriculum should be integrated into these skill areas, should be appropriate for local needs, should be relevant for the students and the times, and should meet the needs of the students (21). Knowledge in skills-based health education should not be limited to health-related concepts for the purposes of learning facts because that makes the curriculum “incomplete and inadequate” (23). <br /><br />Instructional methods in skills-based health education should be “student-centered, interactive and experiential” (23). This includes, but is not limited to, the following instructional strategies: role play, large and small group discussions, debates, cooperative learning, problem solving, brainstorming, and games/simulations (6, 23). Lecture or direct instruction, usually associated with disseminating factual knowledge or concepts, is not included in this list. The implication is that the focus in skills-based health education is not on the acquisition of facts/concepts alone, but on the larger aim of teaching skills, changing attitudes and influencing behaviors through the use of more interactive teaching methods.<br /><br />The instructional methods used in skills-based health education are based around the premise that learning occurs in a social context and that the learning environment is student-centered and allows for social interactions (24). Students learn from the people around them including their teachers, peers, parents and other role models in their lives. This is especially important to consider due to the fact that during adolescence peer pressure and the perception of peer behaviors have been found to influence behavior (25). It would follow that it is important to address norms of health-related behaviors to help influence students’ attitudes towards certain behaviors, to acknowledge and listen to what students’ believe are the behaviors their peers are engaging in, to allow time for practice and feedback so that students can see each other applying skills successfully, and to address the influences in their lives that will guide their decisions. Direct instruction may not have the same impact on the students because it eliminates much of the social context of learning. Student centered learning environments and social interaction can be facilitated best through participatory learning through the use of discussion, brainstorming, role plays, and other techniques discussed above (6, 24).<br /><br /><b>Defense of Intervention 1: Effective Health Education IS Skills-Based</b><br /><b><br /></b>Research examining effective prevention programs (not just school-based) also supports the fact that skills are a core component of effective programming. Nation et al. discussed five principles of effective programs: varied teaching methods, comprehensive, theory driven, opportunities for positive relationships and sufficient dosage (26). Most relevant to health education are varied teaching methods, comprehensive programs and opportunities for positive relationships. Teaching methods found to be most successful are active, skill-based approaches that include interactive, hands-on experiences that increase participants’ skills (26). Greenberg et al. support this finding as they found that modeling behaviors with opportunity for rehearsal and feedback, having students set behavioral goals, and including cues to prompt behavior in a variety of settings are effective techniques in prevention programs (27). These are all methods of the participatory learning style that is associated with skills-based health education.<br /><br />Nation et al. identified comprehensive programs as ones that have multiple interventions and multiple settings (26). “Multiple interventions” refers to addressing issues from multiple perspectives such as increasing awareness and skill teaching (26). Skills-based health education uses a variety of learning experiences and interventions from skill teaching and practice, to providing relevant information about the health-related concepts, to addressing norms about behaviors, to using group processes for learning. Research about prevention programs has revealed that teaching across multiple settings (school, community, peers) improves outcomes. In skills-based health education, health-related concepts and skills should be taught and applied in a variety of settings. One of the most important is the peer setting because of the significant influence peers have on health behaviors especially during adolescence. <span class="Apple-tab-span" style="white-space: pre;"> </span>Finally, the interactive nature of participatory teaching methods used in skills-based health education provide an opportunity to work with other students in a safe environment through role play, small and large group discussions and other group processes that allow students to foster positive relationships.<br /><br /><b>Defense of Intervention 2: Theory Supports It</b><br /><br />This skills-based approach is also supported by Bandura’s Social Cognitive Theory (SCT) (14). The multifaceted components of SCT are an effective framework for supporting the three main aspects of a skills-based health education approach which are: knowledge, skills and attitudes/beliefs. SCT suggests that health behavior is determined by the following influences: knowledge, self-efficacy, outcome expectations, goals and perceived facilitators and impediments (14).<br /><br />The knowledge component of SCT addresses the fact that skills-based health education includes both content and skill knowledge because students need to know and understand certain concepts before they can apply them in their own lives and/or demonstrate their learning in the classroom. Skills-based health education also helps students develop self-efficacy through the opportunity for skill practice and evaluation of their skill performance. These opportunities also allow for teaching and learning regarding the attitudes and beliefs of certain health behaviors (both health-enhancing and risky behaviors) and the potential effects (or outcomes) of performing a certain skill or health behavior. Skills-based health education offers the opportunity for that type of learning to occur.<br /><br />Lastly, certain skills included in the standards, specifically: goal-setting, analyzing influences, accessing information, and advocating for self and others, can help students learn to set goals and recognize facilitators and impediments in their lives. Goals along with facilitators and impediments are the remaining two determinants of health behavior according to SCT (14, 21). In addition to the research that supports the use of skills-based health education, SCT supplies a theoretical framework which furthers the case for skills-based health education.<br />In addition, unlike a traditional approach to health education, a skills-based approach also addresses multiple components of an ecological approach to health promotion as well as provides opportunities to use principles of effective public health campaigning such as social influences, targeted messages, branding, etc. This approach to health education is directly supported by SCT but also includes many opportunities to bring in core components of other health behavior theories and public health approaches.<br /><b><br /></b><b>Defense of Intervention 3: Provides a New Frame</b><br /><br />Shifting from a traditional approach to health education to a skills-based health approach provides an opportunity to reframe the discussion from trying to justify why an approach which is not support by research or public health best practice (traditional) really does belong in schools – really! Instead, health education can be framed as an engaging, relevant, current and research-based approach which combines research and best practice from education and public health to meet the needs of students.<br /><br />The frame could be “Students Need Skills” with a core position that a skills-based approach is a core subject that teaches students essential skills which they need in order to be healthy for life. This frame would be a position of strength and could build on some of the key points of the current frames but use them in a more proactive and positive way. It would also weaken the “it doesn’t belong in schools” frame as the core skills included (i.e., goal-setting, decision-making) are all skills included in the 21st century skills framework and are all included in other core subjects. This would change the language used in discussions since the argument would no longer be about who should be providing students with information or whether it belongs in schools, rather it will be that schools are a place where students develop skills that they need to be successful which also supports the relevance and place for a skills-based approach to health education in schools.<br /><br /><b>Conclusion</b><br /><br />Health education has the potential to be an effective public health intervention which can make an impact on the health of youth. However, the current emphasis on a traditional approach which focuses on disseminating information through a didactic approach is not working. The proposed intervention is a skills-based approach to health education which would address the main critiques of the traditional approach and provide an opportunity for a new frame which will further strengthen the proposed approach.<br /><br /><br /><b>References</b><br /><br />1)<span class="Apple-tab-span" style="white-space: pre;"> </span>Kann L, Telljohann SK, Wooley SF. Health education: Results from the School Health Policies and Programs Study 2006. Journal of School Health, 2007; 77(8): 408-434.<br /><br />2)<span class="Apple-tab-span" style="white-space: pre;"> </span>Centers for Disease Control and Prevention. Health and Academics. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/healthyyouth/health_and_academics/pdf/health-academic-achievement.pdf<br /><br />3)<span class="Apple-tab-span" style="white-space: pre;"> </span>Lewallan TC. (2004). Healthy learning environments. ASCD: Info Brief, 38. Retrieved July 29, 2008 from www.ascd.org.<br /><br />4)<span class="Apple-tab-span" style="white-space: pre;"> </span>Novello AC, Degraw C, Kleinman DV. Healthy children ready to learn: An essential collaboration between health and education. Public Health Reports, 1992; 197(1): 3-15.<br /><br />5)<span class="Apple-tab-span" style="white-space: pre;"> </span>Symons CW, Cinelli B, James TC, Groff P. Bridging student health risks and academic achievement through comprehensive school health programs. Journal of School Health, 2007<br />;67(6):220-227.<br /><br />6)<span class="Apple-tab-span" style="white-space: pre;"> </span>World Health Organization (WHO). (2003). Skills for Health. Information Series on School Health. http://www.who.int/school_youth_health/media/en/sch_skills4health_03.pdf.<br /><br />7)<span class="Apple-tab-span" style="white-space: pre;"> </span>Centers for Disease Control and Prevention. School Health Profiles. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/healthyyouth/profiles/index.htm<br /><br />8)<span class="Apple-tab-span" style="white-space: pre;"> </span>Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health 2008;98:2229-2236.<br /><br />9)<span class="Apple-tab-span" style="white-space: pre;"> </span>Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. Journal of the American Medical Association 2000; 284:723-728.<br /><br />10)<span class="Apple-tab-span" style="white-space: pre;"> </span> Prinstein MJ, Boergers J, Spirito, A. Adolescents’ and their friends’ health-related behavior: Factors that alters or add to peer influence, 2001. Journal of Pediatric Psychology. 2001; 26(5): 287-298.<br /><br />11)<span class="Apple-tab-span" style="white-space: pre;"> </span>Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/HealthyYouth/yrbs/index.htm<br /><br />12)<span class="Apple-tab-span" style="white-space: pre;"> </span> United Nations Educational, Scientific and Cultural Organization. Teaching and Learning for a Sustainable Future. http://www.unesco.org/education/tlsf/mods/theme_b/mod08.html?panel=5#top<br /><br />13)<span class="Apple-tab-span" style="white-space: pre;"> </span> Arborelius E, Bremberg S. How do teenagers respond to a consistently student-centered program of health education at school? International Journal of Adolescent Medicine and Health, 1991;5(2):95-112.<br /><br />14)<span class="Apple-tab-span" style="white-space: pre;"> </span> Bandura A. Health promotion by social cognitive means. Health Education &amp; Behavior, 2004;31:143-164.<br /><br />15)<span class="Apple-tab-span" style="white-space: pre;"> </span>Following the herd (pp. 53-71). In: Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008, pp. 53-71.<br /><br />16)<span class="Apple-tab-span" style="white-space: pre;"> </span>Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(extra issue):80-94.<br /><br />17)<span class="Apple-tab-span" style="white-space: pre;"> </span>Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001;10:3-5.<br /><br />18)<span class="Apple-tab-span" style="white-space: pre;"> </span>Randolph W, Viswanath K. Lessons Learned from Public Health Mass Media Campaigns: Marketing Health in a Crowded Media World. Annual Review of Public Health 2004;25:419-437.<br /><br />19)<span class="Apple-tab-span" style="white-space: pre;"> </span> National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896). Available at: http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf<br /><br />20)<span class="Apple-tab-span" style="white-space: pre;"> </span>Nemours. Parents, Teachers Want More Health, PE Classes. KidsHealth. http://kidshealth.org/parent/kh_misc/health-pe-survey.html<br /><br />21)<span class="Apple-tab-span" style="white-space: pre;"> </span>Joint Committee on National Health Education Standards [Joint Committee]. National Health Education Standards: Achieving Excellence. 2nd Ed. Athens, GA: The American Cancer Society: 2007.<br /><br />22)<span class="Apple-tab-span" style="white-space: pre;"> </span> Tappe MK, Wilbur KM, Telljohann SK, Jensen MJ. Articulation of the National Health Education Standards to support learning and healthy behaviors among students. American Journal of Health Education, 2009;40(4): 245-253.<br /><br />23)<span class="Apple-tab-span" style="white-space: pre;"> </span> Centers for Disease Control and Prevention. Characteristics of an Effective Health Education Curriculum. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/Healthyyouth/SHER/characteristics/index.htm<br /><br />24)<span class="Apple-tab-span" style="white-space: pre;"> </span> Tobler NS, Stratton HH. Effectiveness of school-based drug prevention programs: A meta-analysis of the research. The Journal of Primary Prevention, 1997;18(1):71-119.<br /><br />25)<span class="Apple-tab-span" style="white-space: pre;"> </span> Borders MJ. Project Hero: A goal-setting and healthy decision-making program. Journal of School Health, 2009; 79(5): 239-243.<br /><br />26)<span class="Apple-tab-span" style="white-space: pre;"> </span> Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morrisey-Kane E, Davino, K. What works in prevention: Principles of effective prevention programs. American Psychologist, 2003; 58(6/7): 449-456.<br /><br />27)<span class="Apple-tab-span" style="white-space: pre;"> </span> Greenberg MT, Weissberg RP, O’Brien MU, Zins JE, Fredericks L, Resnik H, Elias MJ. Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist, 2003; 58(6/7):466-474.<br /><br />Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com1tag:blogger.com,1999:blog-1488559550102903823.post-75156418060329120132014-12-18T13:29:00.000-08:002014-12-18T13:29:47.135-08:00Calorie Labeling at Point of Purchase in Chain Restaurants and Food Establishments: How Educating Fails to Combat Consumer Behavior -Emily Lawrence<b>Introduction</b><br /><br />Approximately one in three of American adults and one in six American children are obese &nbsp;(1). The rise of obesity in America is a result of a verity of complex factors, one of which is the way that Americans eat has changed (1). Americans now consume approximately one third of their calories outside of the home and spend almost half of their annual food budget outside of the home (2,3). These restaurant and fast foods are typically higher in calories, sugar and fat and their calorie content is usually underestimated by the consumers (2,3). On November 25, 2014 the Food and Drug Administration (FDA) finalized two rules under the 2010 Patient Protection and Affordable Care Act to address this issue of lack of awareness and overconsumption of calorie dense food (4). The rules require that chain restaurants, similar food establishments and vending machines with 20 or more locations must clearly list calorie information on menus and menu boards next to the name or price of the item. The objective of the rules is to help consumers make informed and healthy diet choices for themselves and for their families (2, 4). Although some states and restaurants have already implemented calorie labeling on menus, this new legislation sets a uniform standard for all states (2). In order to help patrons recognize the significance of the calorie information menu boards will display this statement “2,000 calories a day is used for general nutrition advice, but calorie needs vary” (2).<br /><br />The theory behind menu labeling is that if consumers are confronted with the calorie content of their food at the point of purchase, they may adjust their purchasing pattern and by doing so, may influence food localities to offer healthier options (5). The design of the Calorie Labeling Policy follows a Health Belief Model (HBM), which does not align appropriately with the target population, consumers. The objective of the Calorie Labeling Policy is to present consumers with facts, in this case, calories about their food options when eating out, thus “cueing” them to choose healthier food options. In addition to this cost-benefit analysis, “cues to action” are used to “push” individuals to act; in this case, the calorie labels are a “cue to action” (7). <br /><br />There are multiple flaws within the design of the Calorie Labeling Policy. To begin with, the policy assumes that consumers undergo a rational weighting of health costs and benefits when making food choices at the point of purchase. In fact consumers often prioritize taste, convenience, price and hunger over health when making food based decisions. Additionally, the policy uses calorie labeling on menus to inform and influence consumer behavior, however this may confuse consumers more than it helps them. Finally, the policy assumes that by informing consumers on the nutritional content of their food, they motivate them to make healthier food choices. The problem is that intention doesn’t always lead to action. These fundamental flaws in the policy prevent it from accomplishing its objectives.<br /><br /><b>Flaw 1: Assuming that consumers make rational choices.&nbsp;</b><br /><br />The Calorie Labeling Policy assumes that by increasing consumers awareness on calorie content will allow consumers to make a rational cost-benefit-analysis about what food item to choose in relation to how it will impact their health and or weight (6-9). This model, like other individual level models, is flawed because assumes that individuals always undergo a rational weighing of cost and benefits when making a health related decision. In the context of the Calorie Labeling Policy, it also assumes that consumers value their health and nutrition and will use the calorie labels to weigh the costs and benefits of choosing an item in relation to how it will affect their health. The use of this model underestimates the strength of other factors consumers are confronted with when deciding what food to order. Taste, price, convenience, along with the bombardment of media and advertising influences are likely play heavily in consumer behavior (6).<br /><br />In a qualitative study by Schindler et al of 105 low-income New York City residence it was found that the majority of participants had noticed or heard of menu labels, but had not used them (14). The study found that habitual ordering, confusion over labels, price and hunger were common barriers to menu label use. For example, some participants mentioned that they go to fast food restaurants because they are hungry and choose their food items based on its ability to relieve hunger. One focus group participant mentioned, “I notice the calories, but if I’m really hungry…gimme that beef and potato, you know I’m looking for something to fill me. (14)” Other participants noted that the calorie count does in fact prompt them to weigh the risks and benefits of ordering the item, however they end up rationalizing ordering what they want. For example, one focus group participant came to the conclusion that &nbsp;“It [calorie label] doesn’t really affect what I eat because I’ll say, oh ok I’ll just run it off this week or in my sleep I’ll burn the calories. (14)” These focus group participants demonstrate that at times consumers may in fact go through a cost-benefit analysis when ordering food items, however they are not weighing it in relation to their health, rather in relation to other factors, like hunger.<br /><br />Habits, consumer loyalty and marketing influences also play strongly on consumers’ inability to rationally weigh the health costs and benefits of a food item. In the Study by Schindler some participants mentioned that they know what food item they are going to buy before they even enter the food establishment (14). This demonstrates the influence of fast food marketing and its influence on consumer loyalty to a product. The pervasiveness of fast food marketing in America and its impact on consumer purchasing patterns has huge impactions on the ability of American consumers to make rational diet decisions. This policy falls short because it does not understand what consumers’ value and it overestimates consumers’ ability to make rational health choices at the point of purchase.<br /><br /><b>Flaw 2: The Cue to Action results in inaction&nbsp;</b><br /><br />The calorie labeling policy is based on the fact that most consumers underestimate the number of calories and fat in foods they order away from home (2,3). According to the Health Belief Model (HBM), after an individual has undergone a cost-benefit-analysis, “cues to action” are needed to motivate an individual to act. In the case of the Calorie Labeling Policy, the calorie labels are meant to push or motivate consumers to make healthier food options. The fundamental problem with the “cue to action in this policy is that not all consumers understand the “cue”.<br />In a review of New York fast food restaurant boards, where calorie labeling has been in effect since 2008, it was found that calorie ranges for combination meals; flavor differences and customizations can vary substantially. This makes it difficult for consumers to determine the calorie content of a specific food item (17). Additionally, in a cross-sectional study by Pulos et al in Piece County, WA, it was found that 49% of customers did not understand the food labels (20). Schindler et al explains that not only are ranges confusing, but the relative value of the calories also present difficulties for consumers. Study participants mentioned confusion about the meaning of calories as well as presentation of large calorie ranges for combination meals was unclear. This confusion even led some focus group participants to distrust the label’s accuracy (14).<br /><span class="Apple-tab-span" style="white-space: pre;"> </span>Though the policy attempts to help consumers understand the caloric significance of each food item by labeling each menu with the declaration that “2,000 calories a day is used for general nutrition advice, but calorie needs vary”, it is not sufficient enough to help consumers understand the calorie impact of their food. As demonstrated in the work of Schindler et al, often consumers do not know what the caloric value of their other daily foods are, so they might not understand how this one meal fits into their entire day (14). Additionally, the ambiguity of the statement “but calorie needs may vary”, may lead consumers to believe that they are an exception to the rule and therefor not use the calorie label to make their meal choice. Without providing clear tools for consumers to understand the calorie content of food items, this policy fails on “cuing” consumers to make healthier food choices.<br /><br /><b>Flaw 3: Intention does not lead to action&nbsp;</b><br /><br />In a study by Ebel et al it was found that 27.7% of consumers in Philadelphia who saw calorie labels reported that it influenced their food choice, however when Ebel compared those customers to a control group in Baltimore, no changes were detected in the number of calories purchased (15). The empirical research thus far supports Ebel’s findings. Changes in consumer intention to purchase healthier options does not result in changes to their purchasing patterns (14, 18-20).<br /><br />There is empirical evidence showing that there is often disconnect between intention and action with health related behaviors. In a review of 47 studies on social cognition models, like HBS, over two thirds of the studies found that a belief in ones ability to preform an action did not actually correspond to action (21). This is explained in the fact HBS and the Calorie Labeling Policy are based on the notion that behavior results from knowledge, desire and intent. The policy does not take into account the strong emotional and habitual nuances of human behavior. In the book Predictably Irrational by Dan Ariely he explains, “ We all systematically under-predict the degree to which [emotional] arousal completely negates our superego, and the way emotions can take control of our behavior. (22)” In terms of the Calorie Labeling Policy, labeling calories doesn’t work because eating is not only a physical need, but a social and emotional behavior. Food acts as comfort to individuals, it satiates our hunger both physically and emotionally. According to Ariely’s logic, this means that we cannot predict food choices or change them based on the acquisition of new knowledge on the number of calories in each portion.<br /><br />This policy does not take into account human behavior or emotion, instead &nbsp;it takes a very simplistic view of behavior by assuming that exposure to caloric information on food and drink items will be enough to deter consumers from ordering high calorie items. In a New York Times article, George Lowenstein, a behavioral economist, enforces this point “There are very few cases where social scientists have documented that giving people information has changed their behavior very much…Changing prices and changing convenience have big impacts. Providing information doesn’t. (10)<br /><br /><b>Proposed Intervention</b><br /><br /><span class="Apple-tab-span" style="white-space: pre;"> </span>As an alternative to the Calorie Labeling Policy in food establishments, I propose a campaign to combat the influence of Big Food Corporations like Coca-Cola, McDonald’s, Pepsi, Burger King and other fast food conglomerates. The campaign would that use different group level behavior change tactics, like advertising and Theory of Diffusion Innovation to deter individuals from over-consuming high calorie dense foods. This campaign would involve a re-framing of the issue, the goal would no longer be prevent individual consumer behavior, but rather shift the blame and responsibility to the big food companies. This new frame would then be implemented through marketing and branding approach, using many of the theories and tactics of anti-tobacco campaigns like the “Truth” ads and targeted through school networks and media. The campaigns major objectives would be to impact the American population on an emotional level and expose the manipulation of the Big Food corporations and the consequences they have had on American families. This is in stark contrast to the rational choice model presented in the Calorie Labeling Policy. <br /><br /><b>Defense 1: The campaign focuses on freedom, not health</b><br /><br /><span class="Apple-tab-span" style="white-space: pre;"> </span>A frame is a method of packaging and arranging an issue so that it tells a certain story (23). One of the major flaws with the Calorie Labeling Policy is that it is framed in a way that places health as a core value and sends the message that it is the responsibility of the consumer to make rational, healthy options based on caloric information. The current Calorie Labeling Policy frame obstructs the idea of personal autonomy and life-style choices, when it should empower them. This proposed campaign would use fundamental American core value of individual freedom, a value that is deeply ingrained in American culture. According to Meashe and Siegel “although health is an important core value for the public and policy makers, personal freedoms, civil liberties and individual rights may be even more compelling values.(23)”<br />The core position of the proposed campaign would be that Big Food &nbsp;Corporations have manipulated Americans and thus caused negative effect of on American culture and that their advertising techniques have thwarted our ability to make independent choices. Images of individuals, particularly children, affected by obesity caused by Big Food would enforce our message and capture consumer emotion. By shifting the frame, we can shift the blame of the Obesity epidemic. Reframing the issue could have powerful effects not only on consumer behavior, but also on public health policy that gets to the route of the obesity problem.<br /><span class="Apple-tab-span" style="white-space: pre;"> </span><br /><br /><b>Defense 2: The campaign fights fire with fire &nbsp;</b><br /><br />An inherent flaw of the Calorie Labeling policy that it is based on the presumption that intention leads to action and that by empowering people with information, they will be able to overcome their predisposition for these convenient, high calorie, intensity flavorful and convenient food items. &nbsp;In his book Fast Food Nation, Eric Scholosser explains that (11);<br />&nbsp;McDonald’s spends more money on advertising and marketing than on any other brand. As a result it has replaced Coca-Cola as the world’s most famous brand. McDonald’s operates more playgrounds than any other private entitiy in the United States. It is one of the nation’s largest distributors of toys. A survey of American school children found that 96% could identify Ronald McDonald. The only fictional character with a higher degree of recognition was Santa Claus. The impact of McDonald’s on the way we live today is hard to overstate. The Golden Arches are now more widely recognized than the Christian cross. (11)<br /><br />In a systematic review of 123 peer-reviewed studies by the Institute of Medicine, it was found that food marketing deliberately targets young children, who cannot distinguish advertising from truth, thus strongly motivating their food and drink preferences, requests and consumption (12,13). The study concludes that, “some forms of marketing increase the risk of obesity, cannot be rejected (12).” Fast food marketing is not exclusive to children, with decades of exposure the majority of American citizens have experienced of television, newspaper, magazine and environmental advertising, fast food companies have manipulated and continue to manipulate consumer choices regarding consumer choices and loyalties (6, 16). <br /><br />In order to truly fight consumption of high calorie foods in chain restaurant establishments, Public Health Advocates and Legislatures need to fight fire with fire. Instead of simply attempting to educate consumers about the calories in their fast food choices, there needs to be a concerted effort to form marketing campaigns that fight against the presumptions made in fast food marketing. The proposed campaign will do this by using the same social marketing techniques employed by the anti-tobacco ‘Truth’ campaign.<br /><br />The ‘Truth’ campaign looked for inspiration from the very population their campaign was targeting. They used focus groups and interviews to understand emotion behind smoking “we learned that a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making. (24)” Branding was also used to create an identity for those who opposed the tobacco industry, this helped to accumulate awareness and bolster loyalty to the cause (24). By using these same techniques and focusing on those individuals who are affected by obesity and/or big food and target our campaign messages on the emotional factors that influence fast food consumer behavior.<br /><br /><b>Defense 3: The campaign uses social innovations theory&nbsp;</b><br /><br />An alternative approach to intervening with consumers at the point of purchase and relying on a ‘cue to action’ is to use the theory of diffusion innovation to influence consumer behavior before they even enter food establishments or vending machines. The proposed campaign will use the Theory of Diffusion Innovation primarily with children and adolescents. Children and Adolescence are more easily influenced by media and peers and, spend approximately $30 billion of their own money on fast food and junk food and have significant influence over the eating habits of their families (13). The Theory of Diffusion &nbsp;Innovations states that “adoption of a new idea, behavior, or product does not happen simultaneously in a social system; rather it is a process whereby some people are more apt to adopt than others (25).”<br /><br />A key component of the Theory of Diffusion of Innovation is the targeting of innovators, or people who are willing to take risks and who ultimately take the risks and start the innovation. Since one component of our campaign is to target schools, we would assess the social environment of each school and identify individuals who have the most social influence among their peers. These individuals would become the “innovators” of the campaign and according to the Theory of Diffusion Innovation, these innovators would then influence their peers to join the campaign (25). This method of using both school popularity and media presents a more effective platform for influencing consumer purchasing behavior because it focuses on changing social norms as opposed to changing consumer knowledge.<br /><br /><b>Conclusion&nbsp;</b><br /><b><br /></b>The Calorie Labeling Policy has been implemented to educate consumers on the nutritional content of the food they are purchasing in chain restaurants and vending machines. Though there is nothing inherently wrong with consumer education, however the reality is that it does very little to impact consumer behavior. Obesity is epidemic in America and if Public Health Advocates want any chance at denting fast food and junk food consumption, new strategies that target the emotions and not the knowledge of consumers is needed. Public Health Advocates can no longer rely on consumers to value their health or act rationally when making daily food choices. I propose a campaign that focuses on changing consumer behavior through emotion and taking the blame off of the individual and onto the shoulders of the Big Food corporations. This comprehensive campaign uses mass media and school advocacy to change the way that Americans not only view their food choices, but view the entire food system.<br /><br /><b>References&nbsp;</b><br /><b><br /></b>1)<span class="Apple-tab-span" style="white-space: pre;"> </span>Centers for Disease Control and Prevention. Overweight and Obesity. 2013. http://www.cdc.gov/CDCTV/ObesityEpidemic/<br /><br />2)<span class="Apple-tab-span" style="white-space: pre;"> </span>U.S. Food and Drug Administration. Press Release: FDA finalizes menu and vending machine calorie labeling rules. 2014. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm423952.htm<br /><br />3)<span class="Apple-tab-span" style="white-space: pre;"> </span> Centers for Disease Control and Prevention. Adult Obesity Facts. 2014. &nbsp;http://www.cdc.gov/obesity/data/adult.html<br /><br />4)<span class="Apple-tab-span" style="white-space: pre;"> </span>U.S. Food and Drug Administration. Labeling Nutrition. 2014 http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm248732.htm<br /><br />5)<span class="Apple-tab-span" style="white-space: pre;"> </span>Jennifer L. Pomeranz &amp; Kelly D. Brownell, Legal and Public Health Considerations Affecting the Success, Reach, and Impact of Menu-Labeling Laws, 98 AM. J. Public. Health. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2509596/<br /><br />6)<span class="Apple-tab-span" style="white-space: pre;"> </span>Kriegar J, Saelens BE. Impact of Menu Labeling on Consumer Behavior: A 2008-2012 Update. Minneapolis MN: Healthy Eating Research.2013.Available at: http://healthyeatingresearch.org. <br /><br />7)<span class="Apple-tab-span" style="white-space: pre;"> </span> National Cancer Institute. Theory at a Glance: A guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21<br /><br />8)<span class="Apple-tab-span" style="white-space: pre;"> </span>Rosenstok I., Strecher V., Becker M.Social Learning Theory and the Health Belief Model. Health Education Q. 1988 Summer;15(2):175-83. http://deepblue.lib.umich.edu/bitstream/handle/2027.42/67783/10.1177_109019?sequence=2<br /><br />9)<span class="Apple-tab-span" style="white-space: pre;"> </span>Barton S, Creyer E, Kees J, et al. Attacking the Obesity Epidemic: The 27. Potential Health Benefits of Providing Nutrition Information in Restaurants. American Journal of Public Health, 96(9): 1669–1675, September 2006.<br /><br />10)<span class="Apple-tab-span" style="white-space: pre;"> </span>Tavernise S. The New York Times. Calories on menus: Nationwide Experiment Into Human Behavior. 2014. &nbsp;http://www.nytimes.com/2014/11/27/upshot/calories-on-menus-a-nationwide-experiment-into-human-behavior.html?_r=0&amp;abt=0002&amp;abg=1<br /><br />11)<span class="Apple-tab-span" style="white-space: pre;"> </span> Schlosser. Fast Food nation: The Dark Side of the All-American Meal. New York, Ny. First Mariner Books edition. 2011<br /><br />12)<span class="Apple-tab-span" style="white-space: pre;"> </span> McGinnis JM, Gootman JA, Kraak VI, eds. Food marketing to children and youth: threat or opportunity? Washington, D.C.: National Academies Press, 2006<br /><br />13)<span class="Apple-tab-span" style="white-space: pre;"> </span>Nestle. Food marketing and Childhood Obesity-A Matter of Policy. New England Journal of Medicine. 2006; 354:2527-2529. http://www.nejm.org.ezproxy.bu.edu/doi/full/10.1056/NEJMp068014#ref1<br /><br />14)<span class="Apple-tab-span" style="white-space: pre;"> </span> Schindler J., Kiszko K., Abrams C., Islam N., Elbel B., Environmental and Individual Factors Affecting Menu Labeling Utilization: A Qualitative Research Study, Journal of the Academy of Nutrition and Dietetics 2013; Volume 113, Issue<br /><br />15)<span class="Apple-tab-span" style="white-space: pre;"> </span> Elbel B., Kersh R., Victoria L., Brescoll, Dixon L., Calorie Labeling and Food Choices: A First Look At The Effects On Low-Income People In New York City. Health Affairs. 2009; vol. 28 no. 6 w1110-w1121 http://content.healthaffairs.org/content/28/6/w1110<br /><br />16)<span class="Apple-tab-span" style="white-space: pre;"> </span>J Harms and D Kellner, Toward a critical theory of advertising, University of Texas Illuminations website, n.d., viewed 27 August 2010, http://www.uta.edu/huma/illuminations/kell6.htm<br /><br />17)<span class="Apple-tab-span" style="white-space: pre;"> </span>Cohn EG, Larson EL, Araujo C, Sawyer V, Williams O. Calorie postings in chain restaurants in a low-income urban neighborhood: Measuring practical utility and policy compliance. J Urban Health. Aug 2012;89(4): 587-597.<br /><br />18)<span class="Apple-tab-span" style="white-space: pre;"> </span>Pulos E, Leng K. Evaluation of a voluntary menu-labeling program in full-service restaurants. Am J Public Health. Jun 2010;100(6):1035-1039.<br /><br />19)<span class="Apple-tab-span" style="white-space: pre;"> </span> Thunström L,Nordström J.Does easily accessible nutritional labelling increase consumption of healthy meals away from home? A field experiment measuring the impact of a point-of-purchase healthy symbol on lunch sales. http://bit.ly/ZL8yqz.<br /><br />20)<span class="Apple-tab-span" style="white-space: pre;"> </span>Tandon PS, Wright J, Zhou C, Rogers CB, Christakis DA. Nutrition menu labeling may lead to lower-calorie restaurant meal choices for children. Pediatrics. Feb 2010;125(2):244-248.<br /><br />21)<span class="Apple-tab-span" style="white-space: pre;"> </span> Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003;22:424-428<br /><br />22)<span class="Apple-tab-span" style="white-space: pre;"> </span>Ariely D., Predictably Irrational: The Hidden Forces that Shape our Decisions. New York Ny. HaperCollins. 2009.<br /><br />23)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp;Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues-United States, 1985-1996.Journal of Health Communication 1988; 3(4):307-325.<br /><br />24)<span class="Apple-tab-span" style="white-space: pre;"> </span> Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5<br /><br />25)<span class="Apple-tab-span" style="white-space: pre;"> </span> Boston University School of Public Health. Behavioral Change Models: Diffusion of Innovation Theory. Boston, MA: Boston University School of Public Health. http://sphweb.bumc.bu.edu/otlt/MPHModules/SB/SB721Models/SB721-Models4.html<br /><br />Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-72142899308659651202014-12-18T13:22:00.004-08:002014-12-18T13:25:59.593-08:00A Critical Look at the Don’t Be a Lab Rat Campaign on Marijuana Use Prevention Efforts Among Teenagers – Kara Sewalk<div><span style="font-family: Georgia, serif;">With the evolving legalization of marijuana in the United States, public health professionals, lawmakers, politicians and community members have raised concerns of marijuana use in the United States, particularly focusing on the youth of America. The Official State of Colorado Website for Retail Marijuana Information and Resources maintains that, “according to the 2011 Healthy Kids Colorado Survey, approximately 55 percent of youth tried marijuana at least once by the time they reached 12th grade. The percentage of youth that perceive marijuana use as dangerous is declining” (1). This concern is being addressed in the Don’t Be a Lab Rat campaign, a $2 million campaign funded by the state of Colorado that the city of Denver launched in the summer of 2014, which markets the adverse effects of marijuana use to teenager’s 12 to 15 years olds (2). The Don’t Be a Lab Rat campaign premise is simple: to dissuade teens from smoking marijuana, the argument is made that not enough scientific evidence is available to show the true effects of the drug on the human brain, particularly on the developing brain of teens. Therefore, teenagers who smoke marijuana become the test subjects for future studies on adverse effects of the drug. &nbsp;The campaign is backed up with human-sized rat cages placed in areas around the city of Denver where teens frequent to give a visual on what it is like to be a test rat. Television advertisements are also run which state the possible consequences of marijuana use among teenagers, the data of which, while mostly speculation, comes across extremely frightening to viewers. The full campaign can be explored at www.dontbealabrat.com.&nbsp;</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">Marijuana use among teenagers is a widely recognized public health concern; however, this intervention is a flawed approach to address the issue. The campaign targets individual viewers and does not take into the account social influences on marijuana use, the negative imagery associated with the campaign is adversely affecting it’s own success, and finally the campaign is flawed in the delivery of the anti-marijuana message to the target audience.&nbsp;</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><b>Critique Argument 1: Flaws in Targeting the Individual</b></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The Don’t Be a Lab Rat campaign relies on perceived threats to health by the individual. The campaign, targeted to teenagers 12 to 15 years old, assumes that those who see the campaign will learn that marijuana is potentially extremely dangerous, particularly to developing teenage brains and therefore one should not experiment with the drug. The campaign implements the health belief model to get this message across. The health belief model is one of the most widely used traditional interventions in health education and promotion and has six steps that individuals undergo to motivate themselves to act out or refrain from a particular health behavior. The core of the theory includes perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy (3). There are a number of flaws in relying on the Health Belief Model in the Don’t Be a Lab Rat campaign. The greatest weakness of implementing this model is that it focuses on the individual person’s internal drive to reduce a health behavior. It assumes that a teenager exposed to this campaign will perceive him or her-self as being at high risk to being exposed to marijuana. The campaign also assumes that teenagers will recognize the “laundry list of troubling side effects [such as] schizophrenia, permanent IQ loss and stunted brain growth” (2) as severe threats to health. In addition, the target audience will make the rational decision that marijuana use has no benefits while the perceived benefits of not smoking marijuana will be a healthier life, free of becoming a test subject in future studies on adverse effects of the drug use among teenagers. The campaign could be identified as the cue to action to get teenagers to not experiment with marijuana, because of the potential troubling side effects. There is a major flaw in relying on individualized interventions and assuming a rational thought process in behavior change. Currently, the perceived risk of marijuana use is quite low among teenagers (4) which explains this campaign aims to drastically increase how teens view smoking the drug. However, the need to boost the perceived severity of the behavior does not necessarily equate to the behavior change, which is what this campaign assumes. Using the health belief model, the campaign assumes that teenagers will value their future health and that the potential adverse effects for using marijuana are too high to pick up the drug. What the campaign does not acknowledge is that health is an extremely weak core value, particularly among teenagers. It may be difficult for teenagers to see the perceived benefits of health, particularly when the study acknowledges that these risks are only speculated. Health is generally undervalued and often taken for granted. The health belief model is an ineffective tool in the Don’t Be A Lab Rat campaign because it relies too heavily on the assumption that individual teenagers will rationally make the decision that the potential side effects of using marijuana are too high a threat to experiment. However, it does not address the social or environmental factors that are even more influential to a teenager’s behavior (3). The advertisements of this campaign are specifically designed to induce fear into the target audience. Often the decision to try marijuana happens in social settings, which has much stronger influence over behavior change than an individual’s personal knowledge of harm that may (or may not) result. For this reason, an individualized perspective to behavior change is a flawed mechanism for the effectiveness in reducing teen marijuana use in Colorado.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><b>Critique Argument 2: Flaws in the Visual Images</b></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><span class="Apple-tab-span" style="white-space: pre;"> </span>One aspect of the Don’t Be a Lab Rat campaign that undermines the success of the intervention is the use of rat cages throughout the city. The purpose of the human-sized rat cages placed outside the Denver Public Library and local Colorado skate parks where teens frequent is to give the harsh visual of what is it actually like to be inside a rat cage. The effect is also intended to have a high shock value. With the ability to let people walk inside a giant rat cage, the campaign hopes to express the vulnerability and suffocation of what being a lab experiment subject is truly like. The use of such a visual is intended to bring a harsh reality check to teens that those who use marijuana are indeed lab rats for future studies. However, this is a crude and unnecessary representation that has flawed the intervention. The core message of the campaign is, at this point in time there is inconclusive data on the harmful effects of marijuana use on developing brains. The rat cages do not have any purpose but to patronize and induce fear into those who use or are thinking about using the drug. &nbsp;This is an ineffective method to reduce the rates of teens using marijuana and ineffective in creating awareness of potentially dangerous effects of the drug. Fear as a core message in any intervention will not be met with success, particularly among teenagers (9). The entire message is overshadowed by the immense and dramatic delivery through the human-sized rat cages. In addition, the visual display is not respected in the city as it had quickly been vandalized with the words, “Smoking weed saved my life” and “Scientists can’t wait to see the positive effects it has on your brain” (6). The reason why the use of rat cages is a flaw to this campaign is due to the social reaction theory and the communications theory. The social reaction theory, also known as the labeling theory states that when a person does a behavior, they are defined by the behavior and consequently finds a personal identity in the label given to them by the behavior, which reinforces the repetition of said behavior (8). In the Don’t Be a Lab Rat campaign, teens that have used marijuana are labeled as “Lab Rats” and are stigmatized to become merely test subjects that have no hope but to await future studies to tell them more conclusive data on what adverse health effects to expect. The label of being a “Lab Rat” would therefore become the identity of those who currently use marijuana, which will reinforce the behavior. While the campaign is designed to scare off teenagers from experimenting with the drug, it has no premise for those who have already. The campaign offers no advice or help for teenagers who have experimented with marijuana but do not want to become “lab rats”. Rather, it leaves teens to become the identity they are labeled as which is a major flaw in the implementation of this campaign. The communication theory is the basic principle that people respond better to persuasive messages when they have a connection with the object delivering the message (7). While it should matter what the message is, such as potential adverse effects of teenage marijuana use, it is really how well liked or how well received the delivery is. In the case of the Don’t Be a Lab Rat campaign, the delivery of the message through the use of rat cages is not effective. There is no familiarity of the audience to the image of being a rat in a cage because this visual is not relatable. There is no sense of self-represented in a human-sized rat cages. This campaign works directly against communications theory because the use of rat-cages is the polar-opposite of what any person can relate to. The campaign demeans the audience because teenagers are not rats and they are not test subjects, which results in the message not effectively working on the target demographic, a major flaw in the construction of this campaign.&nbsp;</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><b>Critique Argument 3: Flaws in the Delivery of the Message&nbsp;</b></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The delivery of the Don’t Be a Lab Rat campaign is the greatest flaw. The campaign runs fear-inducing messages to prevent teenagers from using marijuana. The campaign has a number of troubling statistics presented to the teenage demographic, that are designed to frighten the audience out of doing the behavior. Dramatized statistics used in this campaign include, “Teens who smoke pot at risk for later schizophrenia, psychosis”, “Who’s going to risk their brains to find out once and for all what marijuana really does?”, “You can’t escape the negative effects weed has on the teenage brain”, “Legal pot might make America’s kids stupider, say researchers”, “Smoking, vaping, the teenage brain can’t tell the difference”, “Weed can drop a teen’s IQ from average to the bottom 30%. Are you good with 70% of the world being smarter than you?”, and lastly “Care to volunteer for further research?” (2). The intimidation tactic is a direct use of the fear appeal theory. Fear appeal theory is a type of communication used in campaigns that attempts to bring fear to the audience as motivation to protect them from a particular behavior (9). The metaphor of being a lab rat is comparable to the failed “This is your brain on drugs” campaign, which also used the fear appeal theory to prevent substance abuse. “These campaigns are based on the assumption that by vividly demonstrating negative and life-endangering consequences of risk behaviors, people will be motivated to reduce their current risk behavior and adopt safer alternative behaviors”(9). However, studies have found that provoking fear as an intervention method is not successful in creating behavior change about the perceived health threat. Fear may actually result in “defensive reactions such as risk denial, biased information processing and allocating less attention to the health promotion messages, thus rendering threatening health information an ineffective behavior change method” (9). The delivery of fear in the Don’t Be a Lab Rat campaign is an ineffective tool to create the intended behavior change to prevent teens for using marijuana. The tone conveyed in the message is condescending to the target audience and has the potential to have the defensive reactions to the risk of the behavior, which is exactly of what the campaign was intended for. Additionally, according to the ideas of the psychological reactance theory, telling the audience not to do something will actually provoke them to engage in the behavior (8). And in the case of the Don’t Be a Lab Rat campaign, the title itself is ordering the audience of teenagers not to use marijuana and become a “Lab Rat”, which has great potential to establish a reactance among teenagers to do the exact opposite. This psychological reactance actually promotes what the campaign is designed against, making this a major flaw in the design of this intervention.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><b>Articulation of proposed intervention:&nbsp;</b></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">The core goal of this intervention is not just to reduce the rates of teenage use of marijuana. The overarching aim of the Don’t Be A Lab Rat campaign is to increase awareness of the potential adverse effects of using marijuana on developing teenage brains. Among teenagers, there is not much recognition that marijuana has adverse affects (1), particularly with the developing government legalization or decriminalization of the drug throughout the nation. With proper knowledge of the risks of using marijuana, teenagers can actively decide whether to use or not to use the drug. Increasing awareness of the risks of marijuana use among teenagers can have a positive effect on decreasing the rates of teenagers that use marijuana. While there is much debate on the true nature of harm that marijuana causes, the Don’t Be Lab Rat campaign focuses on the risk considering the speculated data provided. While there is no hard evidence marijuana actually causes schizophrenia, decreased IQ levels or stunted brain grown, in the next thirty years there could be. Basing an intervention on speculation and fear does not have the basis to be a successful public health campaign. Three interventions that should be considered to improve the campaign’s aim to improve the awareness of adverse affects of the drug and subsequently reduce rates of teenagers using marijuana include: Focus on social influences rather than individual behavior change; Create a model for behavior change; And finally, redesign the delivery with youth involvement. These interventions, based on social behavioral principles and theories, will improve the reception and effectiveness that the Don’t Be A Lab Rat attempts to have in improving teenage awareness of marijuana effects and subsequent use of the drug.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><b>Defense of Intervention 1: Focus on Social Influence</b></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">The flaws in targeting individual behavior change through the Health Belief Model used by the Don’t Be a Lab Rat campaign could be improved if the focus shifted to the group level rather than the individual. There is much power held in social influences at the group level that can be used in changing the attitudes and behavior use of marijuana, particularly among teenagers. In fact, teenagers often base their decisions on what they think their peers do. The social norms theory could have a positive influence on reducing the rates of teenage marijuana use and perception. The Don’t Be a Lab Rat campaign does have the exaggerated statistics that could be beneficial. However, instead of targeting the individual’s perception of the drug, target the group level using the social norms theory, which uses misconceptions about changing behavior to push people in a better direction. For example, Montana developed an educational campaign to reduce alcohol use among college students by advertising that “most” students have less than 4 drinks each week (13). By suggesting to the audience what seems to be the social norm, a campaign can effectively change behaviors of the individual, because the group will act how they think those around them are acting. In the case of reducing the rates of teen marijuana users, the campaign should focus on the declining rates of marijuana use in the state of Colorado. Bringing attention to how the group behaves can have an influence on an individuals own behavior change. For example, if the campaign advertisements said, “Most Colorado teens don’t use marijuana” those teens who see the advertisements today would think it’s the social norm around their peer group not to use marijuana, so they may not either.&nbsp;</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><b>Defense of Intervention 2: Modeling Behavior</b></span></div><div><span style="font-family: Georgia, serif;"><b><br /></b></span></div><div><span style="font-family: Georgia, serif;">An important aspect of the Don’t Be a Lab Rat campaign that has sparked controversial debate is the terminology of defining those who use marijuana. Labeling marijuana users as “Lab Rats” is an ineffective approach to influence teens not to use marijuana. According to the psychological reactance theory (12), This label stigmatizes those who use the drug and could possibly influence those who use to continue using as they have already been deemed “Lab Rats.” &nbsp;In order to support the aim of reducing rates of teen marijuana use, a more effective tool to use would be a positive label that would influence teens to join the cause, rather than be patronized by it. The labeling theory looks at how groups “create and apply definitions for deviant behavior” such as marijuana use among teenagers (9). Instead of using a negative label of what teenagers can become by using marijuana, the intervention should focus on a positive label that encourages teens to choose not to use the drug. The positive label will enforce healthy behavior, and give teenagers the control over deciding to become a marijuana-free individual. Creating a label that teens can positively identify with allows them ownership of their decision, rather than being told not to engage in the behavior. Additionally, the modeling theory should be applied in this intervention to give a good example of what marijuana-free teens can aspire to be. The modeling theory “refers to the process whereby people learn through the experiences or credible others, rather than through their own experiences” (14). Using the modeling theory, the campaign can promote well-respected teens throughout the communities in television advertisements and ad campaigns around the city where teenagers typically visit, including but not limited to schools, libraries, youth centers, outdoor sporting areas and shopping malls. Providing young teenagers a role model (in their community or a well-respected teen celebrity) as an example on how to make health-conscious decisions, encourages teens to make the choice not to smoke pot. The campaign would show teens it is the popular thing to not use marijuana and very much socially acceptable to stand up for their right to health. Positive influences would have more of an effect in increasing negative labeling and provoking statements that could actually cause the reverse reaction to marijuana use (15). Empowering the youth to actively seek knowledge on the risks of marijuana use, giving them ownership of their actions, and to be apart of a new movement for marijuana-free teens would be much more effective in reaching the target audience for this intervention than the Don’t Be a Lab Rat campaign.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><b>Defense of Intervention 3: Redesign Delivery with Youth Involvement</b></span></div><div><span style="font-family: Georgia, serif;"><b><br /></b></span></div><div><span style="font-family: Georgia, serif;">When designing a campaign and how to portray the message it is imperative to know the audience the campaign is trying to reach. In the Don’t Be a Lab Rat campaign, the target demographics are teenagers between the ages of 12 to 15 years old. A successful campaign to strive towards in reducing teen marijuana use is the national Truth campaign, directed towards reducing teen tobacco use. The Truth campaign is exemplary in showing how to target youth in health promotion campaigns. In the research done on this campaign there was an overall consensus that youth do not like to be told what to do and that they “want the facts, and then want to be left to make their own educated decision…Tobacco [much like marijuana] was a significant, visible and readily available way for youth to signal that they were in control” (10). Additionally, research done for the Truth campaign found that humor rather than harsh realities are more effective in reaching younger people. It would be beneficial to model a campaign aimed to reduce teen marijuana use to the Truth campaign, particularly in a state like Colorado where the selling marijuana is now legal. Further steps to explore can be modeled after the Truth campaign involving the youth, using humor in advertisements rather than fear, and making a brand of the campaign. While the creative design team for the Don’t Be a Lab Rat campaign “talked to dozens of teens, in groups, on the street, and at concerts” (4), an annual youth summit and youth review boards, much like what the Truth campaign implemented would be most beneficial to create, in order to truly know the audience the campaign is attempting to reach. The involvement of youth in how they would be most receptive to advertisements and messages would greatly impact the success of this campaign.&nbsp;</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">While the Don’t Be a Lab Rat campaign intervention is successful in that it has sparked the conversation of teen marijuana use, it certainly has flaws that inhibit the campaign from effectively reaching the target demographic. With recommendations that include social influences, modeling techniques and involving the youth for a youth-related intervention, the state of Colorado could improve the efforts to increase the knowledge on potential adverse effects of marijuana use among teenagers.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><br /></div><div><span style="font-family: Georgia, serif;"><b>REFERENCES:</b></span></div><div><span style="font-family: Georgia, serif;">(1)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Colorado Marijuana [Internet]. [cited 2014 Dec 11]. Available from: https://sites.google.com/a/state.co.us/marijuana/</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(2)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Don’t Be A Lab Rat [Internet]. [cited 2014 Dec 11]. Available from: http://104.131.228.16/</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(3)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Edberg M. Social and Behavioral Theory in Public Health. Essentials of Health Behavior. Jones and Bartlett; 2007. p. 35–49.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(4)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;8 JDA, 2014. New Colo. marijuana ad campaign captures unknown health impact on teens [Internet]. Colorado Public Radio. [cited 2014 Dec 11]. Available from: http://www.cpr.org/news/story/new-colo-marijuana-ad-campaign-captures-unknown-health-impact-teens</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(5)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Vandals Don’t Take Long To Hit Rat Cages Used In Anti-Pot Ad Campaign [Internet]. [cited 2014 Dec 11]. Available from: http://denver.cbslocal.com/2014/08/11/vandals-dont-take-long-to-hit-rat-cages-used-in-anti-pot-ad-campaign/</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(6)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Ruiter RAC, Kessels LTE, Peters G-JY, Kok G. Sixty years of fear appeal research: current state of the evidence. Int J Psychol. 2014 Apr;49(2):63–70.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(7)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Andrews JC, Netemeyer RG, Durvasula S. Believability and Attitudes toward Alcohol Warning Label Information: The Role of Persuasive Communications Theory. Journal of Public Policy &amp; Marketing. 1990 Jan 1;9:1–15.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(8)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Ritzer G. Encyclopedia of Social Theory [Internet]. 2455 Teller Road, &nbsp;Thousand Oaks &nbsp;California &nbsp;91320 &nbsp;United States: SAGE Publications, Inc.; 2005 [cited 2014 Dec 11]. Available from: http://www.sage ereference.com/view/socialtheory/n161.xml</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(9)<span class="Apple-tab-span" style="white-space: pre;"> </span> &nbsp; &nbsp; &nbsp; &nbsp;Broadhead RS. A Theoretical Critique of the Societal Reaction Approach to Deviance. The Pacific Sociological Review. 1974 Jul 1;17(3):287–312.&nbsp;</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(10)<span class="Apple-tab-span" style="white-space: pre;"> </span>Hicks J. The Strategy behind Florida’s “truth” campaign. Tobacco Control. 2001(10):3–3.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(11)<span class="Apple-tab-span" style="white-space: pre;"> </span>Woller KMP, Buboltz WC, Loveland JM. Psychological Reactance: Examination across Age, Ethnicity, and Gender. The American Journal of Psychology. 2007 Apr 1;120(1):15–24.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(12)<span class="Apple-tab-span" style="white-space: pre;"> </span>Silvia P. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. 2005;27(3):277–84.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(13)<span class="Apple-tab-span" style="white-space: pre;"> </span>Thaler R, Cass S. Following the herd. Nudge: Improving Decisions about Health, Wealth, and Happiness. p. 53–71.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(14)<span class="Apple-tab-span" style="white-space: pre;"> </span>Theories and Applications, part two. Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute; p. 9–21.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;">(15)<span class="Apple-tab-span" style="white-space: pre;"> </span>Brooks-Gunn J, Donahue E. The Power of Positive Marketing. The Future of Children: Children and Electronic Media. 2008;18(1):181–204.</span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><span style="font-family: Georgia, serif;"><br /></span></div><div><br /></div>Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-89271498041669351452014-12-18T13:21:00.000-08:002014-12-18T13:21:14.106-08:00Pouring on the Pounds Ad Critique and Intervention – Jen Hawkins<div class="MsoNormal"><span style="font-family: Georgia, serif; line-height: 32px;"><b>Introduction</b></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>In August 2009 the New York City Department of Health and Mental Hygiene announced a new campaign to reduce the consumption of sugary drinks (1). This ongoing campaign consists of TV spots and printed advertisements placed on subway cars, and is supplemented by information posted on their website. Most of the ads and videos contain a hashtag with the phrase “Pouring on the Pounds” or the question, “Are you pouring on the pounds?”&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The Pouring on the Pounds (POP) ad campaign was initiated to help decrease sugary drink consumption, thereby reducing the rates of obesity and diabetes—and related complications— among both children and adults. While some of the ads were powerful with the necessary shock factor needed to engage a public audience, others failed to have the impact that they could have. This paper critiques certain POP ads as ineffective because 1) they are fear based, 2) they rely on the health belief model without providing strong cost-benefit elements, and 3) they fail to acknowledge the role of herd influence and social conformity.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>Critique 1: Fear Based Advertising</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Several of the POP television ads focus on scaring people into compliant behavior – drinking fewer sugary drinks. One ad in particular explains how overconsumption of sugary drinks “eventually can bring on obesity and diabetes and its serious complications,” which can then lead to blindness, amputations, and even death (2). Part of the ad shows an image of two bandaged feet with toes missing, followed by an open body that is being operated on with the sound of a heart monitor beeping in the background. The machine switches from regular beeping to a high-pitched continuous beep, signaling that the patient has flat-lined and died. While it is true that poorly controlled, untreated diabetes can lead to death, linking sugary drinks to death in a 30 second ad is a bit extreme and unlikely to promote behavior change, as is supported by research on fear based health appeals.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>According to Soames Job, a professor and researcher at University of New South Wales, fear based appeals are often met with little success in health promotion campaigns. An effective campaign, however, “allows for the desired behavior to be reinforced by a reduction in the level of fear…This entails five requirements: 1) fear onset should occur before the desired behavior is offered; 2) the event upon which the fear is based should appear to be likely; 3) a specific desired behavior should be offered as part of the campaign; 4) the level of fear elicited should only be such that the desired behavior offered is sufficient to substantially reduce the fear; 5) fear offset should occur as a reinforcer for the desired behavior, confirming its effectiveness” (3).</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The ad described above does not meet all of these requirements. To proceed numerically, the ad does meet the first requirement by describing the terrible complications that can accompany diabetes before proposing that limiting sugary drink consumption can reduce the likelihood of developing diabetes. Criterion two, however, is not met. While it is true that drinking too many sugary drinks can contribute to becoming obese, which can then contribute to developing diabetes and further lead to amputations or death, the feared outcome is a result of a poorly treated medical condition that usually takes many years to develop and is a result of many prior health issues. A person does not become obese or diabetic overnight and does not develop a severe foot infection that requires amputation quickly either. Frankly, the allusion that sugary drinks lead to amputation and death is a stretch and is not likely for most individuals, particularly not in the immediate future.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Criterion three is met as reducing sugary drinks is a proposed solution to prevent obesity, diabetes, and related complications. Criterion four, however, is unlikely to be met because a) most people will not be fearful of amputations and death as previously discussed and b) those who are afraid of these complications, perhaps because they are obese or diabetic are unlikely to see reducing sugary drinks as sufficient to reduce this fear. I make this assertion because many people know that reducing sugary drinks can have a positive impact on weight and diabetes control, but this single change is unlikely to have a major impact on someone’s health without other significant changes in diet and exercise, especially if a person’s health is poor enough to warrant this fear.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Proceeding to criterion five, fear offset is unlikely to reinforce the desired behavior. As with criterion four, most people will either be unafraid or will be in such poor health that simply reducing sugary drinks will not reduce their fear. Consequently, based on Job’s research, this ad is unlikely to lead to significant behavior change.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Further research supports this assertion. Doctors Witte and Allen also did a meta-analysis of fear appeals in relation to public health. While they found that strong fear appeals are more persuasive than low fear appeals, “strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses” (4). I believe this research is in concordance with Job’s conclusions. This ad utilizes a very strong fear appeal—amputation and death are severe complications of diabetes. However, reducing sugary drink consumption does not seem like it will prevent these complications independently, thereby making it a low-efficacy message. &nbsp;Thus, individuals who drink excess sugary drinks may be prompted to defend their choice, either asserting that such extreme complications are unlikely and will not happen to them, or if they are overweight and/or diabetic, perhaps blaming their medical conditions on genetics or some other comorbid health issue that they do not believe they have any control over. It is also possible that individuals who consume many sugary drinks may justify such behavior as something that brings them joy, which may be difficult to come by if they experience a reduced quality of life due to obesity and/or diabetes.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The impact and effectiveness of fear based health promotion messages has been studied and is only effective in certain circumstances. This particular ad, however, fails to meet the necessary criteria needed to positively impact behavior change as the feared outcome highlighted is so extreme that it will not induce fear in many viewers, and may cause those who actually are morbidly obese or have poorly controlled diabetes to either simply ignore the message because reducing sugary drinks does not seem like it will have a large impact or defend their choice to drink sugary beverages. Additionally, such individuals are likely to feel stigmatized by this ad, further raising their defenses.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>Critique 2: Health Belief Model – Cost Benefit Analysis May Not Lead to Desired Results&nbsp;</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The health belief model is based on the idea that people make health decisions by doing a cost-benefit analysis (5). The perceived severity and susceptibility to a disease is weighed with the perceived benefits and costs of taking a certain action. The ad previously described utilizes the health model by insinuating that anybody who drinks too many sugary drinks is susceptible to becoming obese and developing diabetes, from which severe complications may result, such as amputation or even death. The ad further implies that the action needed to prevent this is simply to switch to water, seltzer, unsweetened tea or fresh fruit. With this “simple” switch, one can be healthy and avoid severe complications. However, for those individuals who do base their behavior on a simple cost-benefit analysis using this ad, the cost of giving up sugary drinks might be too great to warrant replacing them with less sugary alternatives and/or the perceived benefits might not be great enough to warrant the change.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>First, individuals feel ownership over their behavior and giving up a particular behavior can be costly, especially if the behavior is automatic and provides a sense of normalcy and comfort, as may be the case when it comes to drinking sugary drinks (6). This concept is related to choosing to partake in identity-related experiences and behaviors, which can lead to personal happiness (7). While it is easy to tell someone to drink more water and fewer sodas, people often feel a loss when they give up a behavior that plays a recurring part in their life, making it difficult to change that behavior. For example, one study found that teens who planned to be abstinent often were not when faced with temptation. The core idea behind telling people to just say no “assumes that we can turn off our passion at will, at any point, whereas our study shows this assumption to be false” (8). This is likely true of sugary drink consumers as well; just telling them what to do is unlikely to be effective and giving up a favorite beverage may simply be too costly, especially if someone identifies as, say, a Pepsi drinker as opposed to a Coke drinker.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Beyond the cost, this ad portrays amputation and death as the worst outcomes that may arise from obesity and poorly controlled diabetes. Most people who view this ad are not going to view themselves as highly susceptible to either of these outcomes—because they aren’t. Even the average person with diabetes only has roughly a 0.28% chance of having an amputation in any given year, and that includes those who make no effort whatsoever to control their condition (9). While the severity of these outcomes is high, the lack of perceived susceptibility undermines that severity as a force to help people change behavior.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Similarly, the benefits of limiting sugary drink consumption are presented as the avoidance of obesity, diabetes, and resulting complications. However, this ad primarily targets those who do not already have these conditions by saying that over time drinking sugary drinks can lead to such complications, and therefore healthier beverage consumption should start now. However, the perceived benefit of preventing a condition that the person does not have is not very strong. As explained by two university researchers, Resnick and Siegel, “The person is more likely to choose a benefit he or she will obtain immediately…The delay associated with the long-term benefit results in the person discounting that benefit’s value” (10). In other words, the POP ad would have been much stronger if the benefit presented could be experienced or obtained in the present.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Overall, this ad is presented in such a way that the cost of giving up sugary drinks is unlikely to be greater than the benefits, and therefore does not utilize the health belief model in an effective way.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>Critique 3: Health Belief Model – Doesn’t Account for Environmental Factors</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>While the health belief model relies on individuals doing a cost-benefit analysis when they make decisions, many individuals do not do a cost-benefit analysis because they are influenced by environmental factors, such as affordability, accessibility, herd mentality and social conformity. (It is also likely that some individuals do a cost-benefit analysis, but are swayed to make decisions that conflict with the health based analysis due to the social determinants listed above.)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Studies have shown that many individuals choose to drink whatever is convenient, accessible, and affordable. For example, an observational study conducted among 13 schools in Massachusetts found that 71% of sixth and seventh graders who used vending machines available at school purchased a sweetened beverage (i.e., Frutopia, tea, sports drinks, etc.) or regular soda in the previous 7 days (11). Following sweetened beverages other than soda, water was the most frequently purchased beverage. Had sweetened beverages been absent from these vending machines, it is likely that students would have consumed fewer sugary beverages and more water simply because the sweetened beverages would have been more difficult to obtain during the school day. Thus, availability, an environmental factor, can lead to greater behavior change than solely relying on an individual to perform a cost-benefit analysis.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>In addition to purchasing drinks that are accessible, individuals also fall victim to herd mentality and social conformity, which are not accounted for by the health belief model (12, 13). Herd mentality and social conformity involve making decisions based on what others have done, leading people to change their opinions and make choices that help them coalesce with the group. Herd mentality occurs when individuals do whatever the group is doing without really thinking about it. For example, when “the wave” goes around a sports stadium the sports fans are engaging in herd mentality. They raise their arms because many people before them have done it. Most do not think about why they are raising their arms or the pros and cons of such a decision—they simply act. &nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Social conformity is similar in that people do things to fit in and avoid being perceived as “different.” This can be an intentional decision or something that happens quickly on a subconscious level. Let’s imagine a young adult at a dinner party. The hostess asks five people what they want to drink before her and they all ask for Pepsi. When the young lady, the sixth person in line, is asked, she quickly replies, “Pepsi, please.” Perhaps she is conforming intentionally; it is also possible that she answers quickly simply because everyone else had said Pepsi and it is easy to give this reply.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">The dinner party scenario parallels findings from research studies and likely represents how many individuals make beverage choices on a day-to-day basis. For example, this fictional scenario is supported by the Asch line study in which a participant is shown a line and verbally asked to choose which of 3 different lines is the same length (13, 14). This task, however, is completed in a room with four confederates who all choose a line before the participant, often giving the incorrect answer. Each participant completed 12 line judgments and approximately 75% of these participants gave the incorrect answer at least once when the majority of the confederates gave the incorrect answer first. Also, “an average of 35 percent of the overall responses conformed to the incorrect judgments rendered by Asch’s accomplices” (13). When performing this task alone, participants almost never erred.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The point is that people are not doing cost-benefit analyses every time they make a decision. They are also influenced by herd mentality and a human tendency to conform to what others are doing around them. Therefore, the health belief model is inadequate to promote major behavior change for an activity that is often done in public, such as drinking a beverage.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>Intervention Strategy</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>I propose changing three major aspects of the POP campaign. First, the ads based on scare tactics needs to be removed entirely and replaced with ads that use marketing theory and feature people similar to the target audience. Second, school vending machines need to stop selling sodas and sweetened beverages. And third, corner stores need to place unsweetened beverages at the front of stores, in more prominent locations.&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>An ideal ad could consist of two teenage friends at a vending machine. One asks the other what she wants to drink. We see a quick flashback of her on the cheerleading squad taking a sip of water after completing a complicated stunt. We also see her walking her dog with her brother, water bottle in hand. Upbeat music plays in the background. Back in real time, she asks for water. Her friend says, “Really? There’s soda in here too.” “Really,” she replies. “I don’t want to end up on the sidelines because I drank too much sugar.” “Good point,” her friend says. “I guess I’d rather not pour on the pounds either.” The friend then purchases two waters and they walk off happily together.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>Defense 1: Replace Fear-Based Appeals with Advertising Theory&nbsp;</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>As explained in the first critique, fear appeals are often unsuccessful. I propose removing them entirely and replacing them with ads that take advantage of advertising theory, a model successfully used by corporate America to sell billions of dollars of product every year, ranging from cosmetics and clothing to cars and electronics. There is no reason why such tactics cannot also be used for health promotion.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Advertising theory has three major components: a promise, support, and core value (15). A well-done ad must tie all of these elements together in way that has universal appeal. The ad described above successfully accomplishes this. First, it promises that drinking water will both enable people to be included with their peers and family, and maintain a lifestyle they already enjoy. This message has a universal appeal because human beings are hardwired to seek social acceptance and support. For example, adults older than 65 who had impaired perceived social support had 3.86 times the mortality risk compared to adults in the same age group with unimpaired perceived social support (16). It is also common knowledge that teenagers give in to peer pressure in order to fit in and feel accepted. One retrospective study found that, “One-third of both genders identified peer pressure as one of the hardest things they had to face as a teenager” (17).</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">This ad also has strong support and core values. The flashback images are very positive and supported by positive music. They are intended to evoke an “I want that too!” response in the viewer. This ad tells the viewers that drinking water instead of sugary beverages will give them the freedom to live the life they want, surrounded by friends and family, unhindered by excess weight. As freedom and inclusion are very strong core values, this ad is likely to be successful.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>Defense 2: Strengthen Cost-Benefit Elements&nbsp;</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Some individuals do indeed do a cost-benefit analysis when making decisions. As previously discussed, the cost of giving up sugary drinks will be too high for many people, especially if they do not perceive themselves as being susceptible to the horrible complications that can result from untreated diabetes. The ad described above, however, has lowered the cost of cutting out sugary beverages by using speakers with whom the viewer can relate. Additionally, the implied outcome of consuming sugary drinks has been changed to something more realistic, therefore increasing perceived susceptibility. In the immediate future, individuals are more likely to become winded while walking their dog or have trouble playing sports due to weight gain. Having an amputation or dying as a result of diabetes complications is far less likely and difficult for most people to relate to (18).</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>By delivering the message by people who are similar to the viewer, the new ad utilizes communication theory and reduces reactance. According to communication theory, people relate and respond more positively to messengers that they can relate to. Research suggests that, “Similarity can increase the positive force toward compliance by increasing liking for the communicator” (18). This is why the ad features average teenagers, as opposed to an unseen narrator as used in the critiqued POP ad. Similar versions of this ad can be made to addresses other target populations, such as working mothers or children.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">&nbsp;Psychological reactance theory, on the other hand, explains that people will hold onto something tighter when they perceive that it will be taken away (18). This is why the ad focused on the girl maintaining what she had: positive, fun interactions with her team, brother and dog. Instead of taking away her freedom (to drink sweetened beverages), avoiding sugary drinks allows her to keep it. Additionally, since this girl is an average teenager her similarity can help reduce reactance among teenage viewers. Again, research shows that, “similarity can reduce the negative force toward resistance by fostering positive interpretations of the communicator’s actions, particularly the degree of threat in the message” (18). Based on these theories, having a similar speaker who focuses on the benefits of drinking water will help lower the perceived cost of limiting sweetened beverage intake.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>Defense 3: Change Behavior First</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>It is possible to use herd mentality to help further a public health cause. The key is to change behavior first. If people change their behavior, their beliefs will follow because people experience discomfort when their actions are not aligned with their values, leading to cognitive dissonance (19).</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The diffusion of innovations theory involves getting a few people to adopt a behavior, which, upon reaching a tipping point, will lead to many people adopting that behavior (20). This theory also applies to schools and companies, not just individuals. Once a few schools remove sugary drinks from vending machines, more schools are likely to follow, and some people will drink fewer sugary drinks and come to value that decision as a result of cognitive dissonance. The same is true of placing sugary drinks in less prominent store locations and moving unsweetened beverages to the front of the store. As more and more people adopt this healthier behavior, it should catch on and become more commonplace.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>It is also important to discuss how to convince schools and corner stores to make this change. Ideally, either a law would be passed or the schools and corner stores would receive a financial incentive, perhaps from the government or an NGO, to offer healthier options. However, if this was not the case, successfully lobbying even a few schools and corner stores could make a huge difference and lead to a diffusion of innovation. Once these few schools and stores change to emphasize the purchase of unsweetened beverages, it is likely that more will follow. For instance it is plausible that health conscious parents will advocate for healthier vending machine options in their own children’s schools upon hearing of this innovation at other schools. As a result, an increasing number of schools might jump on the bandwagon, thereby leading students to change their behavior, accomplishing the whole point of the intervention.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Overall, improving the ads, removing sweetened beverages from school vending machines, and placing unsweetened beverages in prominent storefront locations will bring the Pouring on the Pounds Campaign increased success.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><br /></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>References</b></span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">1.<span class="Apple-tab-span" style="white-space: pre;"> </span>The New York City Department of Health and Mental Hygiene. Press: New Campaign Asks New Yorkers if They’re “Pouring on the Pounds.” http://www.nyc.gov/html/doh/html/pr2009/pr057-09.shtml</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">2.<span class="Apple-tab-span" style="white-space: pre;"> </span>The New York City Department of Health and Mental Hygiene. Pouring On the Pounds Ad Campaign Archive. http://www.nyc.gov/html/doh/html/living/sugarydrink-media-archive.shtml</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">(* Ad cited is the first one on the above page)</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Soames Job, R. F. Effective and ineffective use of fear in health promotion campaigns. American Journal of Public Health 1988; 78(2):163–167.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">4.<span class="Apple-tab-span" style="white-space: pre;"> </span>Witte, K., &amp; Allen, M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Education &amp; Behavior 2000; 27(5):591–615.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">5.<span class="Apple-tab-span" style="white-space: pre;"> </span>Edberg, M. Individual health behavior theories (pp. 197-211). In: Edberg, M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">6.<span class="Apple-tab-span" style="white-space: pre;"> </span>Pierce J.L., Kostova, T., Dirks, K.T. The state of physhological ownership: Integrating and extending a century of research. Review of General Psychology 2003; 7(1): 84-107.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">7.<span class="Apple-tab-span" style="white-space: pre;"> </span>Palen, L., Coatsworth J.D. Activity-based identity experiences and their relations to problem behavior and psychological well-being in adolescence. Journal of Adolescence 2007; 30(5): 721-737.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">8.<span class="Apple-tab-span" style="white-space: pre;"> </span>Ariely, D. The influence of arousal (pp. 119-138). In: Ariely, D. Predictably Irrational. New York, NY: HarperCollins, 2009.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">9.<span class="Apple-tab-span" style="white-space: pre;"> </span>American Diabetes Association. Statistics About Diabetes. http://www.diabetes.org/diabetes-basics/statistics/</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">10.<span class="Apple-tab-span" style="white-space: pre;"> </span>Resnick, E., Siegel, M. Introduction to Marketing Principles (pp. 87-111). In Resnick, E., Siegel, M. Marketing Public Health. Burlington, MA: Jones and Bartlett Learning, 2013.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">11.<span class="Apple-tab-span" style="white-space: pre;"> </span>Wiecha, J. L., Finkelstein, D., Troped, P. J., Fragala, M., &amp; Peterson, K. E. School vending machine use and fast-food restaurant use are associated with sugar-sweetened beverage intake in youth. Journal of the American Dietetic Association 2006; 106(10):1624–1630&nbsp;</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">12.<span class="Apple-tab-span" style="white-space: pre;"> </span>Thaler, R., Sunstein, C. Following the herd (pp 53-73). In: Thaler, R., Sunstein, C. Nudge. United States: Caravan Books, 2008.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">13.<span class="Apple-tab-span" style="white-space: pre;"> </span>Aronson, E., Aronson, J. Conformity (pp 13-58). In: Aronson, E., Aronson, J. The Social Animal. New York, NY: Worth Publishers, 2007.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">14.<span class="Apple-tab-span" style="white-space: pre;"> </span>Asch, S. E. Effects of group pressure upon the modification and distortion of judgment. In: Guetzkow H, ed. Groups, Leadership and Men. Pittsburgh, PA: Carnegie Press, 1951.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">15.<span class="Apple-tab-span" style="white-space: pre;"> </span>Resnick, E., Siegel, M. Marketing Public Health. Burlington, MA: Jones and Bartlett Learning, 2013.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">16.<span class="Apple-tab-span" style="white-space: pre;"> </span>Blazer, D. G. Social support and mortality in an elderly community population. American Journal of Epidemiology 1982; 115(5):684–694.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">17.<span class="Apple-tab-span" style="white-space: pre;"> </span>Brown, BB. The extent and effects of peer pressure among high school students: A retrospective analysis. Journal of Youth and Adolescence 1982; 11(2): 121-133.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">18.<span class="Apple-tab-span" style="white-space: pre;"> </span>Silvia, P.J. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(3):277-284.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">19.<span class="Apple-tab-span" style="white-space: pre;"> </span> Aronson, E., Aronson, J. Self-Justification (pp 181-252). In: Aronson, E., Aronson, J. The Social Animal. New York, NY: Worth Publishers, 2007.</span></span></div><div class="MsoNormal"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">20.<span class="Apple-tab-span" style="white-space: pre;"> </span>Rogers E. Diffusion of Innovations Fifth Edition. New York, NY: Free Press, 2003.</span></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div>Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-85302288004216720392014-12-18T13:16:00.001-08:002014-12-18T13:16:53.739-08:00Fighting Obesity, Not Obese People: A Critique Of Georgia’s Strong4Life Anti Obesity Ad Campaign – Morgan Minogue<div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: Georgia, serif; line-height: 200%;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; A life-threatening epidemic exists in the state of Georgia, placing nearly one million children across the state at increased risk for negative health effects at present, and in the future (1). This epidemic is not one that stems from infection or plagues a certain demographic, but rather one that centers on the behavior of children and their caretakers, and the constructs of the society in which they live. This epidemic is childhood obesity. Across the United States, n</span><span style="font-family: Georgia, serif; line-height: 200%;">ational and state-level public health campaigns address the growing obesity epidemic among</span><span style="font-family: Georgia, serif; line-height: 200%;"> children as a means to prevent adult obesity and promote the future health of the country. In areas of the United States hit hardest by the epidemic, such as Georgia, anti obesity interventions are of great importance, while the steps taken to combat the public health problem have proven controversial.</span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Georgia, second only to Mississippi in terms of the highest prevalence of obesity in the country, has one million children who fall into the category of overweight or obese (2). In 2011, Children’s Healthcare of Atlanta launched Strong4Life, a 5 year 25 million dollar public health intervention aimed at reducing the prevalence of childhood obesity in the state (1). Though the</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Helvetica;"> intervention has evolved greatly following it’s </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Baskerville SemiBold Italic&quot;;">contentious</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Helvetica;"> beginning to include the training of pediatricians, programming in schools, and creation of a clinic to treat the medical and psychological issues related to obesity, the highly disputed advertisements created in the first year of Strong4Life will be the focal point of this critique. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Strong4Life’s initial media campaign called </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">“Stop Childhood Obesity,” took a</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> tough-love approach to combat the alarming rate of childhood obesity in the state. The campaign, established in an effort to fight a genuine and increasingly problematic public health crisis, was nicknamed “Stop Sugarcoating It, Georgia,” as it was designed to shock families into acknowledging obesity as a problem (1). The media campaign includes a series of black and white advertisements produced in the form of both print and television Public Service Announcements, all which feature overweight children making blunt statements about the negative impacts they face in their current state of being obese. In </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;">print ads each child accompanies a warning sign with harsh statements such as “It's hard to be a little girl if you're not, "Big bones didn’t make me this way. Big Meals did,” </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">“Fat prevention begins at home. And the buffet line,” and</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;"> “Fat kids become fat adults” (3). The strong4Life television advertisements evoke a similar tone. In these advertisements, overweight children or their parents ask questions or make strong statements regarding how obesity negatively impacts their health and social status. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Television ads end with a visual “75% of Georgia parents with overweight kids don’t recognize the problem” or “being fat takes the fun out of being a kid” followed by the Strong4Life tag line, “Stop sugarcoating it, Georgia.”(3).</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; In analysis of the media campaign as a tool for behavior change, the following critique evaluates the assumptions Strong4Life made in the creation of the “Stop Childhood Obesity” media campaign. It delves into the theories and research surrounding the tactics Strong4Life used in combatting the issue of childhood obesity. It is important to note that while the media campaign certainly created awareness and was successful in getting people talking about the issue of obesity, it also created unnecessary and harmful stigmatization in the exact population it was trying to help. As indicated in the three criticisms below, the Strong4Life anti obesity advertisements lack the very characteristics needed to foster the change in behavior required to combat the public health issue of childhood obesity. At best, children walks away from the Strong4Life advertisements wanting to make a change, but unequipped to do so. At worst, they walk away shameful and helpless.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Critique Argument 1: Creates Stigma and Shame<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The first major critique of Stong4Life’s “Stop Childhood Obesity” campaign is that it produces stigma and shame in children who struggle with obesity, yielding undesirable heath </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">consequences and lowering self-efficacy among those it seeks to help. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Helvetica;">Self-efficacy, defined as one's belief in their ability to succeed in a specific action, is highly important when creating interventions to target behavior change (4). The promotion of self-efficacy is entirely absent from the Strong4Life media campaign, leaving</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"> kids powerless and unconfident in their ability to take control of and manage their poor health behavior. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">In an interview with NPR regarding Strong4Life’s media campaign, </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Linda Matzigkeit, Vice President of Children's Healthcare of Atlanta, said the campaign “has to be harsh. If it's not, nobody's going to listen.”(2).<i> </i>One Strong4Life television ad, features a young overweight girl who somberly states, “I don’t like going to school, because all the other kids pick on me.” Another pictures a young obese boy, who tells viewers “playing video games is what I like to do by myself, I don’t have to be around the other kids. All they want to do is pick on me.” Both ads end with the visual “Being fat takes the fun out of being a kid.” (3). After analyzing these advertisements, it is evident that Linda Matzigkeit is right about one thing, that these ads are harsh. And as research indicates, the nature of these messages actually harms the very audience they seek to help.&nbsp;&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">At the center of the “Stop Childhood Obesity” campaign is the idea that weight stigmatization </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">is a useful tool of social control in discouraging unhealthy behaviors and</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"> is justifiable </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">when used to improve the health of stigmatized individuals.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"> </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Trebuchet MS&quot;;">Sociologist Erving Goffman defined stigma, in 1963, as “a process by which the reaction of others spoils normal identity”(5). Across American society, it is generally acknowledged that obesity leads to stigmatization, or identity threat. We see in schools, that stigmatization can become so extreme that overweight and obese children fall victim to harsh teasing and bullying from peers (6). This obesity related stigma is known to lead to negative health outcomes, as individuals who face this type of social discrimination tend to internalize it, making them more prone to engaging in unhealthy behaviors (7). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In fact, studies illustrate that overweight children faced with weight-based teasing engage in binge-eating and unhealthy weight control behaviors at a higher rate than their normal weight counterparts, even after controlling for factors including BMI and socioeconomic status (8).</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Trebuchet MS&quot;;"> </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Strong4Life ads place blame on the children without direction, leaving them completely unconfident in their ability to change behavior. The guilt inducing text to present in the advertisements, only further ostracizes and harm a population that already faces a great deal of discrimination though the use of victim blaming. Victim blaming, which leads to viewing behavior as being in control of the individual, promotes increased stigmatization in such obese children, yielding poor heath and psychological and health outcomes (9). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Trebuchet MS&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Weight loss is championed, in Strong4Life’s commercials, on their billboards and across public transportation, as the means to social acceptance and a happier life.&nbsp; However, the n</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">egative nature of these messages actually </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;">yields a decrease in motivation for their target audience, as stigma and shame promoted through television and print advertisements create a diminished sense of self-confidence (10). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Studies indicate that the promotion of self-efficacy through positive messages can lead to healthy choices in those attempting to lose weight. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Verdana;">According to Puhl et al., obesity related health m</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;">essages perceived to be most positive and motivating focus on making healthy behavior changes without referencing an individual’s body weight (10). This is where Strong4Life is flawed, as the Strong4Life campaign centrals entirely on an individual’s state of being overweight or obese, using a negative tone to elicit fear, shame, and guilt in its viewers. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">The Strong4Life campaign assumes that the harsh tactics they use will inspire action, however as indicated above, they actually prove counterproductive as they diminish a children are left unconfident in their ability to change behavior. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Critique 2: Elicits Psychological Reactance in Target Audience<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The Strong4Life media campaign centers on the notion that making children shameful of their health status and fearful of social discrimination will lead to rational food choices. Research suggests the opposite, as advertisements that</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"> stigmatize and blame such a sensitive population, actually yielded an increase in negative food related health behavior (10). A study from Yale University’s Rudd Center for Food Policy and Obesity directly supports this theory, indicating that “</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;">when individuals feel shamed or stigmatized because of weight they're actually more likely to engage in behaviors that reinforce obesity: unhealthy eating, avoidance of physical activity, [and] increased caloric intake”(10). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Trebuchet MS&quot;;">In another study, conducted by Puhl and Brownell, we see similar reactant behavior. In asking over 2400 overweight or obese women how they coped with stigma, 79% of the women said that they coped by eating, while 75% said that they coped by refusing to diet entirely (11). This research indicates that the nature of such message elicit an emotion which spurs action. This emotion is that of personal threat to freedom. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The research above can be explained by the Theory of Psychological Reactance, which </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">centers on the concept of individual freedom, a core value which people hold dear (12). The theory of psychological reactance, developed by Brehm and Brehm in 1966, concludes that if a “person’s behavioral freedom is reduced or threatened with reduction, the person will become motivationally aroused. This arousal would presumably be directed against any further loss of freedom, and it would also be directed toward the reestablishment of whatever freedom had already been lost or threatened” (12). According to this theory, the </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Helvetica;">degree of reactance is affected by the strength of a threat, presence and importance of a freedom, and implication for future threat (12). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; An important application for the promotion of psychological reactance in a health intervention is that when faced with the pressure to change, an individual will often react to a threat by acting in direct opposition to the proposed message (12). A 2008 study by</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;"> Considine and Quick, supports this theory.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"> In their study, which </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial; mso-bidi-font-weight: bold;">examined the use of forceful language in designing exercise persuasive messages for adults, they found that </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">forceful language yielded a feeling of threat among participants, translating into reactant behavior in the form of anger and negative emotions (13). At the center of the “Stop Childhood Obesity” campaign, we see such threatening, powerful messages present. Across the campaign, advertisements seek to shock families with blunt warnings stating that “chubby kids may not outlive their parents” and “Fat kids become fat adults”(3). The messages present in the Strong4Life campaign, which threaten individual freedom by mitigating free choice, encourage this psychological reactance in children who are obese as they act in a way directly opposing the advertisements original intent. Though advertisements may have been successful in promoting awareness, the provocative wording used in the campaign likely reinforces the unhealthy behavior that originally led to obesity. Thus after seeing and hearing such threats, children become more apt to practice poor health behavior as a way to re-establish the their personal freedom and control.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">Critique Argument 3: Leaves Parents and Kids ill Equipped to Prevent and Manage Childhood Obesity </span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The final major critique regarding </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">the </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Strong4Life media campaign is that it focuses primarily on the individual and his or her state of being obese, failing to employ a preventative approach and lacking</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> the actionable steps children and their parents can take to manage the health issue. According to Children’s Health Care of Atlanta, the “Stop Childhood Obesity” ad campaign was created to promote awareness among the high prevalence of parents who fail to recognize obesity as a medical issue (1). It sought to shock kids into behavior change through acknowledging the debilitating nature of the disease. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;In two of Strong4Life’s billboards, young girls struggling with obesity are pictured along with the phrases “Warning: fat kids become fat adults” and “Warning:</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> chubby kids may not outlive their parents”(3). &nbsp;The only Strong4Life advertisement, which even mentions the prevention, is a print advertisement of an overweight child alongside the phrase “</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Fat prevention begins at home. At the buffet line”(3).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; These </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">advertisements were </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">intended to function as a cue to action. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">The c</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">ampaign, as illustrated above, singularly targets the</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"> individual child and his or her state of being obese, entirely </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">disregarding the notion that normal or underweight children may also be at risk.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> These billboards and PSAs were likely designed with the Health Belief Model in mind, under the assumption that individuals act rationally, and that by knowing the facts and recognizing ones health status, children and parents will change behavior.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp; The Health Belief Model is an individual level health belief theory that has been the foundation of public health interventions for decades. The theory, developed by a group of social psychologists in the 1950’s, details the process an individual goes through in making decisions regarding their health behavior (4). It encompasses the idea that individuals act will act rationally when weighing the costs and benefits of a given behavior. Health seeking behavior of an individual is said to be influenced by four distinct factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (4). &nbsp;Interventions utilizing this model target these components as they hope to motivate individuals to seek health and change their behavior. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Strong4Life’s</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">reliance on promoting perceived susceptibility and severity as triggers for obesity related behavior change proves to be a major limitation across the campaign. In a study </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Arial;">evaluating the accuracy of parental perceptions in children’s weight status, parents of obese and overweight children generally underestimate their child's weight status (14). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Stong4Life’s advertisements target such parents, with the stark visual that “</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">75% of Georgia parents with overweight kids don’t recognize the problem.”(3). Here, strong4Life makes the inaccurate assumption that such a statistic will yield an increase in perceived susceptibility, as parents viewing these advertisements will see the obese children in the ads as a reflection of their own, causing them to address unhealthy behavior in the family. However, advertisements simply</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> highlight the health problem of childhood obesity, without addressing </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">solutions to prevent or steps to manage it. As the research indicates, many parents deny or fail to categorize their child as overweight or obese (14). Thus as viewers, such parents would not recognize themself or their child as the target audience of such a message. It is unlikely that these advertisements would promote the desired call to action among targeted parents, as they fail to recognize their perceived risk to obesity. This would leave them ignoring the present and future severity of the health problem, and enable a continued disregard of the problem.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; In addressing children, </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">the Strong4Life advertisements create the image that thinner kids are happier kids. One advertisement states “It’s hard to be a little girl, if you’re not.”(3). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Warning Ads, as referenced above, show heavy children discouraged and sad regarding their current state of being overweight or obese. What these ads fail to do, is </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">detail the factors that contributed to the child’s weight status or what he or she can do to relieve herself of the problem.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">In cohesion with the Health Belief Model, Strong4Life’s campaign centralizes on the notion that individual lifestyle choices are the primary factor contributing to childhood obesity, failing to recognize that social or environmental factors that likely have an affect on the public health problem<i>. </i>Though truthful and effective in promoting awareness, these advertisements fail to properly educate families about the susceptibility to and severity of obesity, as they lack important information </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">regarding the risk factors for and health effects of Childhood obesity. Simply warning kids with phrases such as “</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">fat kids become fat adults,” without acknowledging the unhealthy behaviors that lead to the public health issue or the seriousness behind it, only leave them feeling helpless. In fact, there is no </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">mention about what a parent can actually do to prevent or manage childhood obesity other than to 'stop sugarcoating” it.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Articulation of the Strong4Life Alternative: </span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; As part of the 5 year 25 million dollar public health intervention, Strong4Life’s original “Stop Childhood Obesity” ad campaign was simply used to create awareness, the first step the program used to reduce the prevalence of childhood obesity in the state. In sparking a major controversy throughout the state, the media campaign accomplished its goal of creating awareness. However, it failed in many respects, promoting stigma and shame and proving counterproductive in the very population it sought to help. The campaigns main messages, which sought to inspire motivation through fear and shock, left target audiences unconfident and helplessness. While in lacking the prevention and management tools necessary to promote obesity related behavior change, it left families unaware and unable to change behavior.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; An alternative to the Strong4Life campaign is a media campaign targeted towards all children, rather than one that seeks to single out and stigmatize only children who are obese. It would be one that motivates and inspires a healthy lifestyle, rather than one that threatens children’s personal autonomy. And finally, it is an ad campaign that not only promotes awareness, but also addresses prevention and manageable solutions for obesity, through the use of relatable, personal stories. This campaign is the “Love Your Peach Community” campaign. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The goal of the Love Your Peach Community media campaign is similar to that of Strong4Life, to promote awareness regarding an important public health issue. However, this campaign will place its primary emphasis on concepts such as choosing to participate in a healthy lifestyle, and promoting “health” rather than “weight loss” as the key to living a long, healthy life.&nbsp; One of the primary foundations of this ad campaign will be to mold advertisements to specific communities, which is how the campaign got it’s name. Television advertisements will run state-wide, focusing on the use of personal stories to illustrate the seriousness of childhood obesity and the tools needed to prevent and manage it, while print advertisements and billboards will be designed on the community level, by local health departments and health care advocacy groups. Print advertisements designed at the community level will not only be designed by public health professionals, but also by youth, promoting a feeling of solidarity and community wide responsibility and support regarding health promotion. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Through promoting an underlying tone of youth empowerment, the Love Your Peach Community media campaign will promote the idea of becoming a “Peach Community Kid,” using branding as a method of reducing stigma related to obesity, and helping children take control of health related behavior. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Another aspect of the Love Your Peach Community campaign, designed to both inspire and inform, are the campaign wide “I have a right” statements. These come in the form of state and community print advertisements, which centralize on the concept that kids have the right to choose to be free from obesity. In these ads, children of all sizes are featured with one of the “I have a right” statements. These statements include anything from “I have a right to eat healthy food at school lunch” to “I have a right to walkable sidewalks.” The goal of such advertisements is to reframe the issue of childhood obesity in a way that reduces stigma and promotes the need for social, environmental, and individual action. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Defense of Intervention #1: Motivates Behavior Without Blaming the Victim &nbsp;<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Strong4Lifes “Stop Childhood Obesity” campaign used as </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">weight stigmatization as a justifiable means of promoting behavior change, yet backfired </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">as negative messages left children unconfident in their ability to address their health problem, even if they wanted to. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Negative messages such as those portrayed in the Strong4Life campaign are proven to exacerbate the stigma experienced by obese children, lowering their self-esteem (9,10). Low self-esteem experienced from such obesity related stigma, likely inhibits children from combatting the complex decisions often associated with losing weight and eating healthy. Thus addressing this lack of self-esteem should be of primary concern in the</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> Strong4Life’s alternative. The Love Your Peach Community campaign, was creatively crafted with this notion in mind, as it seeks to promote self-efficacy for a healthy lifestyle, through the use of positive messages that promote empowerment and motivation across the target audience<b><o:p></o:p></b></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Puhl and Brownell cite Attribution Theory as a useful framework with which to understand this obesity related labeling, and the stereotypes surrounding obese and overweight individuals (9). <i>&nbsp;</i>According to this model, people associate certain negative connotations with overweight or obese individuals as a way of explaining the underlying causes of their condition (9). The obese are thus often labeled as being lazy, lacking self-control and willpower and even considered “morally irresponsible” (9).</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> In seeking to avoid such harmful obesity related stigma and shame, Love Your Peach Community will focuses on these social factors, attempting to mold social norms around health behavior and promoting a feeling of tolerance regarding all sizes, rather than simply singling out those who are overweight or obese. Though still considered an anti-obesity campaign, Strong4Life’s alternative takes Attribution Theory into consideration, rarely mentioning the word obesity or focusing on an individual child’s state of being overweight or obese. In doing so, the Love Your Peach Community campaign minimizes stigma and bullying originally promoted through Strong4Lifes campaign.</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The focal point of “Love Your Peach Community” advertisements will be to </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">promote an accepting and non-judgmental environment that promotes individual self-esteem and solidarity for health, while changing previous social norms. Advertisements motivate individuals to seek health behavior, rather than blame them for the failure to do so. Through the utilization of branding, advertisements will champion the notion of becoming a “Peach Community Kid.” Love Your Peach Community television advertisements will depict groups of children, all shapes and sizes, getting outside and enjoying all their Peach community has to offer.&nbsp; Once a local board of health decides to become a Georgia’s “Love Your Peach Community,” they will promote the idea of becoming a “Peach Community Kid” on the local level. Schools will promote “Peach Community Days” where children will have the opportunity to take a hands-on approach to promoting health, as they gain exposure to healthy cooking techniques and will have the opportunity to design and manually build a community garden for their school. Unlike the Strong4Life campaign, the Love Your Peach Community campaign will provide a sense of community and belonging for obese children and their families, ultimately diminishing stigma and addressing issues of low self-esteem.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Defense of Intervention #2: </span></b><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia; mso-bidi-font-style: italic;">Sells Freedom of Choice to limit Psychological Reactance<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Strong4Life advertisements left obese children defensive as messages promoted disapproval of their weight status, eliciting physiological reactance in the very children it targeted. The Love Your Peach Community campaign seeks to directly limit the degree to which children feel their freedom is being threatened, by </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">promising freedom and control through the pursuit of health behavior as its main objective. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">One way the Love Your Peach Community campaign will minimize reactance is through the application of Marketing Theory, placing a focus on packaging health promotion in a manner that appeals to the target audience. According to literature, one way to properly do this is through utilization of the perfect</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">messenger, or the individual that delivers the message the campaign seeks to promote</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Messengers, which may be used to deliver information, demonstrate</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"> </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">behavior, or provide testimonials, are proven to enhance audience engagement, as well as promote message credibility and relevance when chosen in the right way (15). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Part of this principle relies heavily on the likability of the messenger, as audiences are likely to feel less threat associated with messages that come from someone they like or can identify with (15). In choosing their messengers, the Strong4Life alternative will use kids of all sizes and backgrounds to deliver inspiring messages about the actions they take to promote health. Some advertisements show adults who were overweight as a child and discuss the very manageable solutions they took in achieving health. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">The Love Your Peach Community campaign will also place a heavy focus on the substance of the message in which the messenger promotes, ensuring it is one that </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">motivates and inspires a healthy lifestyle, rather than one that threatens personal autonomy. Strong4Life generally follows the traditional approach to prevention, as it presents a fear appeal in an effort to focus attention on the negative consequences of a poor health behavior. This Love Your Peach Community takes a different approach, by placing its focus on promoting the desirability in a positive alternative, by creating commercials that champion a child’s right to be free from obesity and the manipulation of the food industry. The campaigns “I have a right” advertisements do just this.&nbsp; By using messengers who </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">practice behaviors that put them at risk for obesity, the Love Your Peach Community campaigns shift the focus to prevention and management while empowering kids to address environmental and social barriers to health. In using the “I have a right” statements, kids begin to obtain a feeling of control regarding their health behavior. These advertisements generally tend to motivate their target audience, as the </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">rewarding gains of healthy lifestyle behavior are promoted as something obtained through choice. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Defense of Intervention #3: Provides Actionable Steps to Manage the Public Health Issue <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The “Love Your Peach Community” campaign takes a different approach to promoting perceived susceptibility and severity to childhood obesity. Rather than simply </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">focusing on the individual child and his or her state of being obese, this campaign takes advantage of peoples distorted perception of risk through the application of the Theory of Unrealistic Optimism. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">Through the use of will state-wide public service announcements, a focus will be placed on the use of personal stories to illustrate the seriousness of childhood obesity as well as the tools needed to prevent and manage it. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">The Theory of Unrealistic Optimism, which explains that individuals perception of risk is not always rational, describes that individuals generally </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;">overestimate their risk of having good things happen to them, while underestimate risk of bad things happening (16). In addition, “among negative events, the more undesirable the event, the stronger the tendency to believe that one’s own chances are less than average.” Strong4Life seeks to take advantage of peoples distorted perception of risk, in promoting perceived susceptibility in the </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">“75% of Georgia parents with overweight or obese children who fail to recognize the health problem.” However, in failing to illustrate the behaviors that led to their child’s weight problem, such parents cannot relate to the message and thus are left to simply disregard the facts.&nbsp; </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Love Your Peach Community tackles this issue in a different manner, </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Times;">highlighting the health problem, while also addressing </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">solutions to prevent and steps to manage it. Across the campaign parents, detail the moment they realized what they were feeding their kids could be causing harm. One mom indicates, “Tamara’s doctors told me her diet was placing her at high risk for future chronic health problems. That was the moment I knew I needed to change the food I was feeding my family.” An ad such as the one described here, is one parents with children at risk can relate to, emphasizing that they too may be at risk of exposure to the debilitating nature obesity. Other advertisements indicate perceived seriousness of childhood obesity showing Brian discussing his classmate and friend Martin. He explains “I never knew my best friend Martin was at risk for harmful disease because of his weight. I never knew the food my school was providing was adding to this risk.” This advertisement ends with one of the Love Our Peach Community slogans “We have a right to be free from harm at school.” This ad specifically, provokes emotion as well as the need for policy change and regulations across Georgia. It acknowledges that there are outside factors contributing to the problem of obesity, outside of individual food choices.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The use of personal stories from both parents and children serve as a mode of creating the perceived susceptibility and severity needed to diminish unhealthy behavior. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Goudy;">Research indicates that among young audiences, emotional messages tend to be better remembered than non-emotional ones and enhance the ads’ effectiveness (17). </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Love Your Peach Community is modeled after Pam Laffin’s Outrage campaign, one of the most successful anti smoking campaigns, </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Goudy;">which used a testimonial format to elicit such emotional response while providing credible information about the severity tobacco use (18). In her campaign, a young mother is depicted dying of smoking related emphysema, while her children are shown faced with the harsh reality of losing their mother (18). Love Your Peach Community follows this model in promoting</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;"> the desired call to action among targeted parents and children as they </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Goudy;">use information to inform families about the harsh realities associated with childhood obesity, with an added benefit of not telling them what to do. </span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: Georgia;">Through use of personal testimonials, families become more likely to listen to the messages presented in the ads. By promoting specific healthy choices, such advertisements yield a sense of personal empowerment in those who view them, while also providing parents and children with the tools necessary to make change happen. &nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-align: justify; text-justify: inter-ideograph;"><br /></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;"><b>REFERENCES</b></span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">1.<span class="Apple-tab-span" style="white-space: pre;"> </span>Strong for Life. We Have a Problem in the Peach State. Children’s Healthcare of Atlanta. 2013. http://www.strong4life.com/pages/about/TheIssue.aspx?</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Lohr K. Controversy Swirls Around Harsh Anti-Obesity Ads. NPR. 2012 http://www.npr.org/2012/01/09/144799538/controversy-swirls-around-harsh-anti-obesity-ads?sc=fb&amp;cc=fp</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Emma G. Georgia Anti-Obesity Ads Say "Stop Sugarcoating" Childhood Obesity. The Huffington Post. 2014. Available from: http://www.huffingtonpost.com/2012/01/03/georgia-anti-obesity-ads-stop-sugarcoating_n_1182023.html</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">4.<span class="Apple-tab-span" style="white-space: pre;"> </span>Individual health behavior sciences (ch 4) in Edberg M. Essentials of Health and Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, pp35-49.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">5.<span class="Apple-tab-span" style="white-space: pre;"> </span> Seeman M, Goffman E. Stigma: Notes on the Management of Spoiled Identity. American Sociological Review. 1964;29(5):770.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">6.<span class="Apple-tab-span" style="white-space: pre;"> </span>Vaidya V. Psychosocial aspects of obesity. Advances in Psychosomatic Medicine 2006;27:73-85.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">7.<span class="Apple-tab-span" style="white-space: pre;"> </span>Stuber J., Meyer I., Link B. Stigma, prejudice, discrimination and health. Social Science and Medicine 2008;67:351-357.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">8.<span class="Apple-tab-span" style="white-space: pre;"> </span>Libbey H, Story M, Neumark-Sztainer D, Boutelle K. Teasing, Disordered Eating Behaviors, and Psychological Morbidities Among Overweight Adolescents. Obesity. 2008;16:S24-S29.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">9.<span class="Apple-tab-span" style="white-space: pre;"> </span>Puhl R, Brownell K. Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias. Obesity Reviews. 2003;4(4):213-227.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">10.<span class="Apple-tab-span" style="white-space: pre;"> </span>Puhl R, Peterson J, Luedicke J. Fighting obesity or obese persons? Public perceptions of obesity-related health messages. Int J Obes Relat Metab Disord. 2012; 37(6):774-782.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">11.<span class="Apple-tab-span" style="white-space: pre;"> </span>Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring) 2006;14(10):1802–1815&nbsp;</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">12.<span class="Apple-tab-span" style="white-space: pre;"> </span>Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">13.<span class="Apple-tab-span" style="white-space: pre;"> </span>Quick, B.; Considine J. &nbsp;Examining the use of forceful language when designing exercise persuasive messages for adults: &nbsp;a test of conceptualizing reactance arousal as a two-step process. &nbsp;Health Communication 2008; 23:483-491</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">14.<span class="Apple-tab-span" style="white-space: pre;"> </span>De La O A, Jordan K, Ortiz K, Moyer-Mileur L, Stoddard G, Friedrichs M et al. Do Parents Accurately Perceive Their Child's Weight Status? Journal of Pediatric Health Care. 2009;23(4):216-221.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">15.<span class="Apple-tab-span" style="white-space: pre;"> </span>Rice R, Atkin C. Public communication campaigns. Thousand Oaks, Calif.: Sage Publications; 2001.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">16.<span class="Apple-tab-span" style="white-space: pre;"> </span>Weinstein N. Smokers' unrealistic optimism about their risk. Tobacco Control. 2005;14(1):55-59.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">17.<span class="Apple-tab-span" style="white-space: pre;"> </span>Lang A, Dhillon K, Dong Q. The effects of emotional arousal and valence on television viewers’ cognitive capacity and memory. Journal of Broadcasting &amp; Electronic Media. 1995;39(3):313-327.</span></span></div><div class="MsoNormal" style="text-align: left;"><span style="font-family: Georgia, serif;"><span style="line-height: 32px;">18.<span class="Apple-tab-span" style="white-space: pre;"> </span>Schar E, Gutierrez K, Murphy-Hoefer R, Nelson DE. Tobacco Use Prevention Media Campaigns: Lessons Learned from Youth in Nine Countries. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. www.cdc.gov/tobacco.</span></span></div><div style="text-align: left;"><br /></div>Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-50593148029659711942014-12-18T13:04:00.000-08:002014-12-18T13:07:54.805-08:00The Role of the Health Belief Model on the Medicalization of Refugee Life - Svyatoslav “Slavvy” Petrov<div class="MsoNormal"><b style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Introduction –</span></b></div><div class="MsoNormal" style="line-height: 200%;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">The Link between the Health Belief Model &amp; Medicalization -<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Over the last two decades, studies of non-Western refuges and asylum-seekers, seen in clinics in Western countries, have proliferated in the cross-cultural mental health and public health literature (14, 31). Not surprisingly, most studies (e.g. 21) indicate a high prevalence of refugees who are diagnosed with posttraumatic stress disorder (PTSD) (14).&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">However, a critical analysis of the PTSD model reveals that there is a poor distinction "between the physiology of normal distress and the physiology of pathological distress, so that overdiagnosis is easy" (30, 31). When refugee experiences of distress are reduced to a pathological entity, trauma becomes psychopathology and a refugee life takes on a medicalized form. This dominant ideology arises from the globalized discourse of trauma solidified by humanitarian organizations such as UNICEF, universalist claims in Western psychiatry that mental disorders are the same everywhere, reductive biomedical training curriculums, and an overdependence on the core assumptions of the Health Belief Model (HBM) (14, 31).&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">As mainstream medicine, psychiatry, and public health become more objective, the socio-political and historical contexts of illness become secondary to prevention, diagnosis and treatment. Positivist medical and public health behavioral models, such as the HBM, make it challenging to understand, assess, and treat non-Western and racialized peoples when the focus of health behaviors is zoomed in on the individual and the historical and socio-cultural elements of health-related decision-making are neglected (34). When illness or a health behavior is de-contextualized, the link between models of illness, symptom presentation and treatment becomes blurred. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">The disconnect between individual and culture in the HBM is a significant problem in cross-cultural refugee care and especially in refugee mental health needs-assessment and services. Frequently, refugee identities amount to patients inflicted with "post traumatic stress" (31). This, as Summerfield argues, occurs because there is "a missed identification between the individual and the social world, and a tendency to transform the social into the biological (the mere machinery of the body)" (31). By reducing the refugee experience to visible symptoms "inside a person (between his or her ears)," the social context and current needs are ignored both in medical and public health interventions (31). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">More importantly, the medicalization of refugee life may be a major barrier to effective physician-refugee-patient relationships. To ensure effective preventive and/or therapeutic encounters with refugees, medical providers and public health practitioners must take a holistic approach; identify the socio-cultural aspects that influence refugee health behavior and illness presentation; address the current social situation and needs of refugee groups and raise clinical and needs-assessment questions that go beyond symptomatology and notions of “perceived susceptibility,” “perceived severity,” and “perceived benefits” (9, 10, 26). To accomplish this, modern medical and public health workers must be willing to resist both the drivers of medicalization and the common assumptions instilled by the HBM.&nbsp;&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">What is Medicalization?: Origins &amp; Modern Drivers -&nbsp; <o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">The term medicalization emerged in the 1970s. Its application was mainly used to critique emerging medical definitions for previously non-medical issues. Explicitly, medicalization refers to the "process by which nonmedical problems become defined and treated as medical problems, usually in terms of illnesses or disorders" (5). In his 1992 article, "Medicalization and Social Control", Conrad expounds upon the social origins of medicalization (5).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Analysts have long pointed to the social factors that have encouraged or abetted medicalization: the diminution of religion, an abiding faith in science, rationality, and progress, the increased prestige and power of the medical profession, the American penchant for individual and technological solution to problems, and a general humanitarian trend in western societies </span></i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">[to pathologize distress and "trauma" in order to galvanize access to public support and sponsorship]. &nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Despite the multiple aspects that reify medicalization, the "organization and structure of the medical profession has an important impact" (5). “Professional dominance and monopolization have certainly had a significant role in giving medicine the jurisdiction over virtually anything to which the label "health" or "illness" could be attached<i>”</i>(8).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">To complicate things, the modern engines that drive medicalization expand beyond the clinical (interactional) level and into the realm of biotechnology (i.e. pharmacology, psychotropic drugs), consumers (i.e. patient choices, elective care), and managed care (i.e. HMOs, coverage of once non-medical problems) (6). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Conrad argues that modern pharmaceutical and biotechnology industries are becoming major facilitators of medicalization (6).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">While physicians are still the gatekeepers for many drugs, the pharmaceutical companies have become a major player in medicalization. In the post-Prozac world, the pharmaceutical industry has been more aggressively promoting their wares to physicians and especially to the public.</span></i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Additionally, Summerfield (31) argues that evidence suggests that the pharmaceutical industry has the power to set research agendas and to endorse unaffordable treatments for non-medical problems.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Industry strategies include casting ordinary processes as medical problems (e.g. baldness), casting mild functional symptoms as portents of serious disease (e.g. irritable bowel syndrome), casting personal or social problems as medical ones (e.g. social phobia), casting risk factors as actual diseases (e.g. osteoporosis), and using misleading disease prevalence estimates to maximize the size of a medical problem (e.g. erectile dysfunction)</span></i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"> <i>(22).<o:p></o:p></i></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Further, as the American medical system changes and provides more choices (e.g. elective cosmetic surgery) consumers (i.e. patients) of healthcare play a significant role in the process of medicalization (6). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">As health care becomes more commodified and subject to market forces, medical care has become more like other products and services. We now are consumers in choosing health insurance plans, purchasing health care in the marketplace, and selecting institutions of care [and] hospitals and health care institutions now compete for patients as consumers. </span></i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><br /></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In our current medical age, consumers have become increasingly vocal and active &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; in their desire and demand for services. Individuals as consumers rather than patients help shape the scope, and sometimes the demand for, medical treatments for human problems.<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In relation to managed care, Conrad (6) suggests that HMOs have assumed an important role in increased use of psychotropic medications in adults and children. He argues that lack of coverage for certain interventions (e.g. talk therapy) forces providers to prescribe treatments that are only covered by patients' insurance plans. This can proliferate medicalization. “It seems likely that physicians prescribe pharmaceutical treatment for psychiatric disorders knowing that these are the types of medical interventions covered under managed care plans, accelerating psychotropic treatments for human problems” (6).<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">All in all, these, largely Western, forces of medicalization construct positivist schemas and facilitate reductionist practices in refugee care. Common paradigms of medicalization allow mental health professionals and public health providers to conflate natural responses to "trauma" with psychopathology. In other words, refugee experiences are conceptualized through an objective lens that zooms in on the individual and his or her pathology, but neglects more pressing, subjective refugee needs. Taking this into account, the discourse of medicalization and the universality of the HBM in the refugee care context is in need of critical assessment. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Rethinking "Trauma" &amp; PTSD -<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In "The Invention of Post-traumatic Stress Disorder and the Social Usefulness of a Psychiatric Category," Dr. Derek Summerfield makes four crucial points about modern conceptualizations of trauma and distress. He argues that 1) "a psychiatric diagnosis is not necessarily a disease, 2) distress or suffering is not psychopathology, 3) PTSD is an entity constructed as much from socio-political ideas as from psychiatric ones, and 4) the increase in the diagnosis of PTSD in society is linked to changes in the relation between individual personhood and modern life" (30). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">These arguments are critical of "the global spread of the [PTSD] diagnosis by humanitarian programmes" (30, 31). The greatest shortcoming of this understanding of trauma is that the "misery and horror [experienced by refugees] is reduced to a technical issue tailored to Western approaches to mental health" and interpreted via a largely Westernized HBM (3, 28, 30, 31). In this vein, refugees' background culture, current situation, and subjective meanings brought to the lived experience are narrowed to a singular diagnosis (30). This is the crux of the problem. Approaching an individual refugee outside of a historical and/or socio-cultural context can create a misjudged classification that all refugees experience and need mental health screening and services.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Furthermore, the liberal application of the PTSD diagnosis reaffirms its natural, objective place in the world as a universal category. Summerfield warns against this and states that "PTSD may be seen as a Western culture-bound syndrome" (32). In this sense, indiscriminant merging of traumatic experiences with a psychiatric disorder is problematic. As Young (35) accentuates,<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;<i>The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; diagnosed, studied, treated, and represented and by the various interests, &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; institutions, and moral arguments that mobilized these efforts and resources</i> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (cited in 30).&nbsp;&nbsp;&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">To drive the point home, Summerfield (31) argues that human experiences should not be categorizes as objective signs of "trauma." Refugee experiences are not universal, and their responses to traumatic events are not always indicative of a mental disorder.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">The fundamental relativity of human experience, even in extreme conditions, and the primacy of the subjective appraisal and social meaning, means that there can be no such thing as a universal trauma response. Human responses to aversive experiences such are not analogous to physical trauma: people do no passively register the impact of external forces (unlike, say, a leg hit by a bullet) but engage with them in an active and problems-solving way. Suffering arises from, and is resolved in, a social context, shaped by the meanings and understandings applied to events (and which may evolve as the context evolves). <o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">With this in mind, public health practitioners must be careful not to generalize and assume that there is an inherent connection between a refugee identity and mental health. What is key here is that public health practitioners must conduct screenings and interventions that are grounded not</span><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;;"> only on the traditional HBM but also expand the current HBM by integrating cultural interpretation and understanding of a what is important to specific refugee groups. This can be achieved through a systematic review or meta-analysis of existing cross-cultural literature and in-depth interviews with refugee patients in order to elicit the role of culture on refugee health behaviors, understanding, and help-seeking. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">"Pathologizing" Refugees -<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Despite lay and clinical ideologies that attempt to naturalize posttraumatic stress as a biological response to distressing events, critical perspectives within the mental health professions suggest that natural responses to traumatic experience should not be agglutinated with pathology (2, 3, 27, 31). In lieu of this criticism, Richman (25) cautions against the pathologising of refugees: <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <i>It is often assumed that all refugee[s]... are 'traumatized' by their experiences, &nbsp;&nbsp; and need specialist treatment, but in practice few refugee[s]... require specialist &nbsp;&nbsp;&nbsp;&nbsp; treatment, and distress can often be relieved without recourse to specialists.<o:p></o:p></i></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">To further the critique, mental health and public health providers question the cultural appropriateness of Western therapeutic interventions with refugees groups. Specifically, in non-western cultures, distress is conceptualized in terms of external factors and social experiences rather than internal emotional processes (29). In "The Social Experience of War and Some Issues for the Humanitarian Field", Summerfield argues that psychiatric therapy and counseling may not be practices familiar to refugees, and sharing one's personal feelings outside the family unit may be considered atypical (27). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In light of these complexities, Summerfield urges that refugees' distress should not be seen in Western terms as PTSD, but should be interpreted as "a normative and adaptive communication" (30). However, Summerfield and others do not disqualify the devastating side-effects of traumatic experiences. They acknowledge that all refugees are entitled to support systems. With this in mind, "support needs to be practical, educational and social, bolstering refugees' resilience rather playing on vulnerabilities" (1, 13, 25). Additionally, Burnett (4) notes that the skills of some refugee community members may be valuable for providing the most culturally appropriate, counseling-like interventions.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Considering the complex and culture-specific refugee responses to "trauma," Hek (13) provides important advice:&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">What is significant is striking an appropriate balance between ensuring that...refugees have access to emotional and psychological support that makes sense to them, does not make them feel stigmatized and takes into account cultural issues, whilst not immediately assuming that all...refugees will need such input (19, 24). The key, as with all service provision, is to see each [refugee] as an individual who is likely to have some similar experiences to others in similar circumstances, and some different experiences; to build on their strengths; promote positive factors in their lives and engage them in the discussion of what they think they need.<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Essentially, refugee experiences are social, political, personal, and situational. In this sense, clinical assessment of refugees should be holistic. Unfortunately, biomedical and psychiatric paradigms of distress have a tendency to reduce these experiences to pathology and neglect more pressing refugee concerns. Mainstream clinical and public health discourse places value on objectivity and the traditional HBM, and tends to medicalize distress, making consideration for social realities and culture an afterthought.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Medicalizing Idioms of Distress -<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">As mentioned earlier, concentration on the psychological status of refugees has enlivened a growing body of research on trauma and PTSD. Nonetheless, scholars (e.g. 23, 27-32) dispute the validity of the term “trauma” as an explanatory model for distressing events. These scholars call PTSD a pseudo-condition, arguing that PTSD and trauma are socially constructed and medicalized. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Summerfield (28) indicates that Western psychiatric communities medicalize distress refugees convey. This occurs because psychiatric models of causation apply biological constructs to the lived experiences of refugees. However, in non-western cultures, distress is not an internal emotional phenomenon (29, 31). Refugees conceptualize distress as external social experiences rather than biological symptoms (15). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">To explain the asymmetry between clinical and indigenous explanatory models of distress, Summerfield (29) provides one compelling reason:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <i>Western cultural trends – accelerating in the twentieth century – towards the &nbsp;&nbsp; medicalization of distress, and the rise of talk therapies, provide the &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; backdrop to the discourse of ‘trauma’. Medicine and psychology have replaced &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; religion as the source of descriptions and explanations of human experience, and individual psychology has come to be seen as the core human nature &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; everywhere.<o:p></o:p></i></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Ironically, while Western medical communities solidify distress and trauma as somatic symptoms requiring therapy, “there is little evidence that those affected [by traumatic experiences] anywhere in the non-Western world have seen their mental health as an important issue apart, and wanted treatment specifically for this” (31). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Although refugees commonly have traumatic histories and sometimes need psychiatric assistance, indiscriminant application of medicalized paradigms of trauma overlooks their pragmatic or culture-bound concerns. Refugees may see doctors for mundane ailments as well as exotic ones, and their concerns may be social and economic, not just biological and psychological. A sole focus on the biological and behavioral ramifications of distress via a reductionist HBM perspective facilitates the medicalization of refugee life itself. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Medicalization of Refugee Life: A Mixed Blessing? - <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Frequently, biomedical conceptualizations of trauma become synonymous with refugees' lived experiences. The Western, culturally-bounded understanding of experiences of violence has a tendency to shift the conversation towards emotional and psychological trauma. Biomedicine and public health follow a similar logic. If traumatic stimuli existed in the past, it must have visible repercussions in the present. In other words, trauma can be pinpointed in a refugee's biology. Such thinking makes it easy to conceive refugees as patients in need of psychiatric assessment. Sometimes, this is a dangerous logic. It amounts to a biomedical generalization that neither considers the context nor the social realities of refugees. A hyperactive medical gaze overlooks the immediate needs of refugees.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">This is not to say that refugees do not need emotional or psychiatric support, but often it is the last thing they seek (31). Correspondingly, Summerfield argues that “there may be risks that the host society offers refugees a sick role rather than what is really sought: opportunities for meaningful citizenship as part of rebuilding a way of life, [learning the host country’s language, finding a place to live or seeking employment opportunities]” (32). Specifically, the biomedical gaze “may reduce still evolving experiences, meanings and priorities of [refugees] to a single category – trauma – so that refugee suffering is too routinely attributed to pre-flight events, neglecting current factors” (32).&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Furthermore, evidence suggests that asylum seekers whose immediate needs are met tend to do better on the social and psychological levels. For example, Dahoud and Pelosi's (7) study of Somali asylum seekers in London revealed that insecure housing, not experience of war, torture or death of relatives, was the predominant variable predicting those who would report mental health issues (cited in 32). Additionally, Gorst-Unsworth and Goldenberg's (12) study demonstrated that in Iraqi asylum seekers in London, poor social support was significantly linked to low mood or depression rather than a history of torture (cited in 32). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">However, despite the pitfalls of modern medicine and psychiatry to address the social realities of refugees, the medicalization of refugee life may be a mixed blessing. Considering that qualification for asylum or refugee status is a complex legal process, attaining a PTSD diagnosis "has become the means by which people seek victim status-and its associated moral high ground-in pursuit of recognition and compensation" (14, 31). In other words, "...a biomedical category has to be used <i>in order to get things done</i>" (14). Likewise, for refugee and asylum seekers, a PTSD diagnosis functions as a legitimizing tool; it is "the royal road to [services and protection] for victims of many different sorts of violence...and until a better system can be devised it would be wrong...and surely be unjust to block off this road" (14). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In this way, although the medicalization of "trauma" reduces refugee experiences to a single illness category, a PTSD diagnosis may be the only way refugees or asylum seekers receive legal authorization to remain in the host country. Additionally, this authorization allows for easier access to needed social and medical services. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Indeed, it is paradoxical that objective conceptualizations of "trauma" and the individual-based principles of the HBM can be transformed into a critical asset necessary for legitimation and "moral exculpation" (30). Ironically, the stakeholders of this legitimation are biomedical providers and public health practitioners who adhere to the naturalized PTSD discourse and the traditional HBM (5): “Physicians [and public health personnel] may function as gatekeepers for benefits that are only legitimate in organizations that adopt a medical definition and approach to a problem, but where the everyday routine work is accomplished by nonmedical personnel.”<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Despite the mixed blessing of medicalization, Summerfield (30) challenges mental health professionals and public health practitioners to consider the ethical dilemma of categorizing and/or diagnosing people with mental conditions they may not have:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">...it might be timely for mental health professionals to review our definition of the disorder as a disease and decide whether it has sufficient robustness and explanatory power to apply to diverse uses to which it is now being put. Society confers on doctors the power to award disease status and social [and legal] advantages attached to the sick role. Current practice, which labels people as being mentally ill when they are not, calls this public duty of doctors into question. To conflate normality and pathology devalues the currency of true illness, promotes abnormal illness behavior, and incurs unnecessary public costs (20).<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Taking the above discussion seriously, medical and public health providers must understand that their role permeates beyond prevention, diagnosis, and treatment and into the very fabric of refugee life and identity. Effective public health interventions and good provider-refugee-relationships may depend on providers' willingness to combine treatment with advocacy, social support, and cultural competency. For this to become a common practice, both concepts and discourse must change about the role culture plays on individual health behaviors. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Changing Concepts - <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Commonly, "medicalization occurs...as part of a doctor-patient interaction, when a physician defines a problem as medical (i.e. gives a medical diagnosis) or treats a "social" problem with a medical form of treatment..." (5). However, in order to ensure effective therapeutic interactions, providers must distinguish that refugees "are largely directing their attention not inwards, to their mental processes, but outwards to their devastated social world" (32). With this in mind, "health professionals have a duty to recognize distress, but also to attend to what the people carrying this distress want to signal by it" (32). To accomplish this, clinicians and public health workers must be attentive not only to health behaviors and/or symptomatology, but also to the social and material needs of their refugee clients (32):<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Health professionals should beware the limitations of looking at the world through a medicotherapeutic prism. The idea that "recovery" from an aversive experience (or "processing" or "healing" or "closure") is a discrete thing is again a legacy of the Cartesian assumptions that launched psychiatry and psychology - that the mental world is separable from the material world and can be instrumentalised separately. In the real world "recovery" is even more slippery than "suffering", and as subject to sociomoral and philosophical considerations. Its setting is people's lives rather than they psychologies.<o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Taking this into consideration, liberal application of medicalized idioms of distress may create asymmetry within a physician-refugee-patient relationship. To avoid clinical misunderstanding, mental health professionals should integrate “indigenous” explanatory models of distress into assessment and treatment of refugee groups. Refugee experiences must not be narrowed to pathology. Providers must find a balance between clinical objectivity and real-world subjectivity. This would involve a reworking of the very premise of the HBM and showing culture equal priority when understanding health behaviors. To actualize this, there must be a change in the HBM-inspired biomedical and public health discourse.&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Changing Biomedical &amp; Public Health Discourse - </span></b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;"><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Effective public health interventions and good physician-refugee-patient relationships may hinge on asking appropriate assessment questions. Before the turn of the eighteenth century, the question of - who are you? and what is the matter with you? - were common clinical inquiries. However, with time, the dynamics of recognition changed. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In <i>The Birth of the Clinic </i>(1994), Foucault addresses the historical and epistemological roots of objectification in the clinical setting. He analyzes how the emerging medical discourse led to the "medical gaze." The change in medical concepts and recognition was fundamental. Over the course of the eighteenth century, the question the physicians asked the patient changed from "What is the matter with <i>you</i>?" to "Where does it <i>hurt</i>?" (cited in 11). In other words, increased biomedical and public health objectivity that transformed how health professional see people.&nbsp; In this sense, persons became patients and patients became carriers of illness. The priority shifted to treating the illness, not the patient in the holistic sense. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Nevertheless, despite this change in the pattern of recognition described by Foucault, qualitative evidence shows that modern physicians still ask, albeit implicitly, the "Who are you?", "How do you feel?", and "What is the matter with you?" questions in order to forge positive clinical relationships (11). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Additionally, in their seminal article, Kleinman and Benson recommend the use of explanatory models to elicit patients' illness experiences. The model consists of the following clinical questions (18): <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; margin-left: .5in;"><i><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">What do you call this problem? What do you believe is the cause of this problem? What course do you expect it to take? How serious is it? What do you think this problem does inside your body? How does it affect your body and your mind? What do you most fear about this condition? What do you most fear about the treatment? <o:p></o:p></span></i></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">However, although such questions are highly applicable in "conventional" and multicultural clinical interactions, they are useful only to translate patient input into familiar biomedical discourse so that clinicians can arrive at a diagnosis and prescribe treatment. Taussig (33), "while applauding the emphasis which the new cross-cultural psychiatry gave to elucidating the patient's model of illness, nonetheless cautioned that the knowledge so obtained could allow the management of the patient to be all the more persuasive or coercive" (cited in 32). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Essentially, Foucault's description of the epistemological shift in clinical questioning and Kleinman's explanatory model approach facilitate the re-coding of lay or culture-bound expressions of illness into more tangible clinical information that can be analyzed and controlled. The goal here is to identify a disease category rather than address the social or material needs of patients. This mentality may not transfer well into refugee care. In this sense, the HBM model needs to be reassessed and reworked to include the concept of culture as a determining factor in health behavior. To start, caring for refugees and asylum seekers may require alternative points of clinical and public health inquiry. <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Adjusting Points of Inquiry - <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">In chapter six of Ingleby’s volume, Summerfield (14, 32) tells a brief anecdote about a Somali asylum seeker (referred to him for psychiatric opinion) who once told him: “Your words are very fine, doctor, but when are you going to start to help me.” Here, the asylum seeker indicates that his distress signals his “focus on practical assistance and advocacy to help bolster [his] immediate social situation” rather than a pursuit of psychiatric therapy or a concern for a mental health problem (14, 32). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Such clinical realities signify that assessment of refugee experiences should “center on practical problems and direct attention to function-focused and problem-focused coping styles… rather than [only] the emotion-focus (14, 32). To step beyond psychopathology and identify actual refugee concerns that are linked to culture, the provider must ask different questions. Questions such as “How are you doing? And What do you need to do?” should prelude “How are you feeling?” (14, 32). <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Asking such questions changes the focus of clinical discourse and adds an opportunity to incorporate a socio-cultural understanding of health to the HBM. It facilitates holistic diagnosis and challenges the universality of distress as a somatic symptom. In this vein, Kleinman (17) argues that although signs of distress (i.e. PTSD) can be identified globally, it is a fallacy to assume that distress carries identical meanings in every cultural context. Likewise, Kleinman and Good (16) claim that “describing how it feels to be grieving or melancholy in another society draws one into an analysis of radically different ways of being a person” (cited in 32).&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">With this in mind, refugees "know that they will stand or fall by what they do in and about [their social] world" (31). Therefore, as discussed above, "for them the key questions [are] not ["where do I hurt?", or "what do I call this problem?", or] 'how am I feeling?' but 'what can I do to bolster my situation?'" (31). Unfortunately, if distress is perpetually relocated from the "social arena to the clinical arena" there is little promise that mutual clinical understanding, patient satisfaction, and healing will occur (31).&nbsp;&nbsp;&nbsp; <o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">If clinicians and public health practitioners become conscious of the socio-cultural determinants of health and look to immediate social realities refugees convey, there is hope that better symmetry may be achieved in screening and therapeutic interactions with refugee groups. Indiscriminant conflation of natural responses to traumatic experiences with psychopathology is the demise of effective clinical practices in refugee care. Likewise, assessment of refugee patients must not only be determined by technical and individual-based considerations or symptomatology, but also by the social, cultural, and humanistic parameters. To put this into practice, clinical concepts and discourse must permeate beyond singular, symptom-driven approaches of the prevailing HBM and address more pressing and practical refugee needs that are linked directly with a culture-bound understanding of health and health-seeking. &nbsp;&nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><b><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Conclusion - <o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 200%; text-indent: .5in;"><span style="font-family: &quot;Georgia&quot;,&quot;serif&quot;; mso-bidi-font-family: &quot;Times New Roman&quot;;">Refugee populations represent a noticeable proportion of patients providers and public health practitioners see. How providers and public health workers assess and treat refugee groups is essential to prevent illness, build new life, and achieve healing. Evidence indicates that best practices in refugee care hinge on providers' ability to recognize the socio-cultural determinants of health and understand the existing social realities of refugee groups. Likewise, effective physician-refugee-patient relationships depend on looking further than psychopathology and medicalized conceptualizations of refugee life. To put this into practice, clinicians and public health providers must challenge existing medical/public health dogma and discourse perpetuated by the narrow application of HBM, and adjust the focus of clinical inquiries to elicit refugees' cultural interpretations of health, practical problems and immediate needs. &nbsp;&nbsp;<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 200%;"><br /></div><div class="MsoNormal"><span style="line-height: 32px;">References –&nbsp;</span><br /><span style="line-height: 32px;">1. Bolloten, B &amp; Spafford, T (1998) Supporting Refugee Children in East London <span class="Apple-tab-span" style="white-space: pre;"> </span>Primary Schools in Rutter, J &amp; Jones, C (Eds.) Refugee Education. Mapping the <span class="Apple-tab-span" style="white-space: pre;"> </span>field. Trentham Books, Wiltshire&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">2. Bracken, PJ. (1998). Hidden agendas: deconstructing post-traumatic stress disorder. <span class="Apple-tab-span" style="white-space: pre;"> </span>In Bracken P, Petty C, editors. Rethinking the trauma of war. New York: Free <span class="Apple-tab-span" style="white-space: pre;"> </span>Association Books; 1998.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">3. Bracken, PJ &amp; Petty, C (1998) Rethinking the Trauma of War. Save the Children. <span class="Apple-tab-span" style="white-space: pre;"> </span>London</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">4. Burnett, A (2002) Guide to Health workers Providing Care for Asylum Seekers and <span class="Apple-tab-span" style="white-space: pre;"> </span>Refugees. Medical Foundation, London</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">5. Conrad, Peter. (1992). Medicalization and Social Control. Annual Review of Sociology <span class="Apple-tab-span" style="white-space: pre;"> </span>18: 209-232.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">6. Conrad, Peter. (2005). The Shifting Engines of Medicalization. Journal of Health and <span class="Apple-tab-span" style="white-space: pre;"> </span>Social <span class="Apple-tab-span" style="white-space: pre;"> </span>Behavior 46(1): 3-14.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">7. Dahoud, O. &amp; Pelosi, A. (1989) The work of the Somali Counseling Program in the UK, <span class="Apple-tab-span" style="white-space: pre;"> </span>Bulletin of the Royal College of Psychiatrists 13, 619-60. &nbsp;</span><br /><span style="line-height: 32px;">8. Freidson, E. (1970). Profession of Medicine. New York: Dodd, Mead&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">9. Glanz, K., Rimer, B.K. &amp; Lewis, F.M. (2002). Health Behavior and Health Education. <span class="Apple-tab-span" style="white-space: pre;"> </span>Theory, Research and Practice.San Fransisco: Wiley &amp; Sons.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">10. Glanz, K., Marcus Lewis, F. &amp; Rimer, B.K. (1997). Theory at a Glance: A Guide for <span class="Apple-tab-span" style="white-space: pre;"> </span>Health Promotion Practice. National Institute of Health.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">11. Good, M. J. D. et al. (2011). Shattering culture: American medicine responds to <span class="Apple-tab-span" style="white-space: pre;"> </span>cultural diversity. Russell Sage Foundation.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">12. Gorst-Unsworth, C. &amp; Goldenberg, E. (1998) Psychological sequelae of torture and <span class="Apple-tab-span" style="white-space: pre;"> </span>organised violence suffered by refugees from Iraq. Trauma-related factors <span class="Apple-tab-span" style="white-space: pre;"> </span>compared to <span class="Apple-tab-span" style="white-space: pre;"> </span>social factors in exile. British Journal of Psychiatry 172, 90-94</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">13. Hek, R. (2005). The experiences and needs of refugee and asylum seeking children <span class="Apple-tab-span" style="white-space: pre;"> </span>in the UK: A literature review.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">14. Ingleby, D. (Ed.). (2005). Forced migration and mental health: Rethinking the care <span class="Apple-tab-span" style="white-space: pre;"> </span>of refugees and displaced persons. Springer.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">15. Kirmayer, L.(1989). Cultural variations in the response to psychiatric disorders and <span class="Apple-tab-span" style="white-space: pre;"> </span>mental distress.Social Science and Medicine 29:327-9.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">16. Kleinman, A., Good, B. (eds) (1985) Culture and Depression: Studies in the <span class="Apple-tab-span" style="white-space: pre;"> </span>Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Berkeley: <span class="Apple-tab-span" style="white-space: pre;"> </span>University of California Press.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">17. Kleinman, A. (1987) Anthropology and psychiatry: The role of culture in cross-<span class="Apple-tab-span" style="white-space: pre;"> </span>cultural research on illness, British Journal of Psychiatry, 151: 447-454.&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">18. Kleinman, A., &amp; Benson, P. 2006 Anthropology in the clinic: the problem of cultural <span class="Apple-tab-span" style="white-space: pre;"> </span>competency and how to fix it. Plos Medicine 3(10): e294.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">19. McCallin, M (1996) The Impact of Current and Traumatic Stressors on the <span class="Apple-tab-span" style="white-space: pre;"> </span>Psychological Well Being of Refugee Communities in M McCallin (Ed.) The <span class="Apple-tab-span" style="white-space: pre;"> </span>Psychological Well-being of Refugee Children: Research, Practice &amp; Policy <span class="Apple-tab-span" style="white-space: pre;"> </span>Issues. International Catholic Child Bureau. Geneva</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">20. Middleton H, Shaw I. (2000). Distinguishing mental illness in primary care. BMJ: <span class="Apple-tab-span" style="white-space: pre;"> </span>320:1420-1421.&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">21. Mollica, R. F., McInnes, K., Pham, T., Fawzi, M. C. S., Murphy, E., &amp; Lin, L. (1998).<span class="Apple-tab-span" style="white-space: pre;"> </span> The dose-effect relationships between torture and psychiatric symptoms in <span class="Apple-tab-span" style="white-space: pre;"> </span>Vietnamese ex-political detainees and a comparison group. The Journal of <span class="Apple-tab-span" style="white-space: pre;"> </span>nervous and mental disease, 186(9), 543-553.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">22. Moynihan, R., Heath, I., &amp; Henry, D. (2002). Selling sickness: the pharmaceutical <span class="Apple-tab-span" style="white-space: pre;"> </span>industry and disease mongering. BMJ: British Medical Journal,324(7342), 886.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">23. Ommeren, M.V., Saxena, S., &amp; Saraceno, B. (2005). Mental and social health during <span class="Apple-tab-span" style="white-space: pre;"> </span>and after acute emergencies: Emerging consensus, Bulletin of the World <span class="Apple-tab-span" style="white-space: pre;"> </span>Health Organization, 83 (1), 71-77.&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">24. Richman, N (1998a) In the midst of the whirlwind. A manual for helping refugee <span class="Apple-tab-span" style="white-space: pre;"> </span>children. Save the Children. London</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">25. Richman, N (1998b) Looking Before and After: Refugees and Asylum Seekers in the <span class="Apple-tab-span" style="white-space: pre;"> </span>West in, PJ Bracken &amp; C Petty (Eds.) Rethinking the Trauma of War. Save the <span class="Apple-tab-span" style="white-space: pre;"> </span>Children. London &nbsp;</span><br /><span style="line-height: 32px;">26. Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health<span class="Apple-tab-span" style="white-space: pre;"> </span> Education Monographs. Vol. 2 No. 4.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">27. Summerfield, D (1998) The social experience of war and some issues for the <span class="Apple-tab-span" style="white-space: pre;"> </span>Humanitarian Field, in PJ Bracken &amp; C Petty (Eds.) Rethinking the Trauma of <span class="Apple-tab-span" style="white-space: pre;"> </span>War. Save the Children. London &nbsp;</span><br /><span style="line-height: 32px;">28. Summerfield, D. (1999). A critique of seven assumptions behind psychological <span class="Apple-tab-span" style="white-space: pre;"> </span>trauma programmes in war-affected areas, Social Science &amp; Medicine, 48, 1449-<span class="Apple-tab-span" style="white-space: pre;"> </span>1462.&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">29. Summerfield, D. (2000) Childhood, War, Refugeedom and ‘Trauma’: Three Core <span class="Apple-tab-span" style="white-space: pre;"> </span>Questions for Mental Health Professionals. Transcultural Psychiatry 37, 417-434.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">30. Summerfield, D. (2001) The invention of post-traumatic stress disorder and the <span class="Apple-tab-span" style="white-space: pre;"> </span>social <span class="Apple-tab-span" style="white-space: pre;"> </span>usefulness of a psychiatric category. British Medical Journal 322, 95-98.&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">31. Summerfield, D. (2004). Cross-cultural Perspectives on the Medicalization of <span class="Apple-tab-span" style="white-space: pre;"> </span>Human Suffering. ISSUES AND CONTROVERSIES, 233.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">32. Summerfield, D. (2005). My whole body is sick… my life is not good. In Forced <span class="Apple-tab-span" style="white-space: pre;"> </span>Migration and Mental Health (pp. 97-114). Springer US.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">33. Taussig, M. (1980) Reification and the consciousness of the patient. Social Science &amp; <span class="Apple-tab-span" style="white-space: pre;"> </span>Medicine 148, 3-13.</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">34. Waldron, I. R. G. &amp; K. McKenzie (2008). Re-conceptualizing "trauma": Examining <span class="Apple-tab-span" style="white-space: pre;"> </span>the mental health impact of discrimination, torture and migration from racialized <span class="Apple-tab-span" style="white-space: pre;"> </span>groups in Toronto.&nbsp;</span><br /><span style="line-height: 32px;"><br /></span><span style="line-height: 32px;">35. Young, A. (1995). The harmony of illusions: inventing posttraumatic stress disorder. <span class="Apple-tab-span" style="white-space: pre;"> </span>Princeton, NJ: Princeton University Press; 1995&nbsp;</span><br /><div style="line-height: 200%;"><br /></div></div>Sarah Robertshttp://www.blogger.com/profile/01641812654924533798noreply@blogger.com0tag:blogger.com,1999:blog-1488559550102903823.post-87423880850846983572014-05-07T11:55:00.002-07:002014-05-07T11:55:17.348-07:00Welcome to the Fall 2014 SB721 Course Blog!On this blog, we will post all of your public health critiques. You will be able to read the papers written by all of your classmates.Michael Siegelhttp://www.blogger.com/profile/09937031813339167454noreply@blogger.com0